CAMP – HIPAA HANDBOOK FORM – ADEC

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CAMP – HIPAA HANDBOOK FORMchristmasz2023-03-15T13:27:08-04:00

CAMP - Acknowledgement of Receipt of HIPAA Privacy Practices Handbook

IMPORTANT: By signing below, I acknowledge that I received a copy of ADEC's Notice of Privacy Practices effective October 1, 2014.

Please print camper's name:(Required)

Camper's address:(Required)

Please print parent or guardian's name, if applicable:

Signature:(Required)

Signature of witness:(Required)

Date:(Required)

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ADEC ADMINISTRATION BUILDING: 1671 W. Vistula St. BRISTOL, INDIANA

(574)848-7451 – [email protected] – OFFICE HOURS: M-F 8AM – 4:30PM

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