Common use of Right to a Paper Copy of This Notice Clause in Contracts

Right to a Paper Copy of This Notice. You may ask us for a paper copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are entitled to receive a paper copy of this Notice. To obtain a paper copy of this Notice, ask any member of staff.. You have the right to file a complaint if you believe that staff has not complied with the practices outlined in this Notice. All complaints must be submitted in writing. You will not be penalized in any way for filing a complaint. If you believe your privacy rights have been violated, you may file a complaint with the NorCal CA 516 Continuum of Care System Administrator. To file a complaint with the Administrative Entity, contact: City of ▇▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇. Redding, CA 96001 Email: ▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ To file a complaint with the State of California, contact: ▇▇▇.▇▇▇▇▇▇▇.▇▇.▇▇▇ ▇▇▇-▇▇▇-▇▇▇▇ ▇▇▇-▇▇▇-▇▇▇▇ By signing this form, you acknowledge receipt of the HMIS Notice of Privacy Practices. Our Notice of Privacy Practices provides information about how we may use and disclose your protected information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by accessing our web site, ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hmis or by contacting any staff person involved in your services. If you have any questions about our Notice of Privacy Practices, please contact: United Way of Northern California ▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ ▇▇, ▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ (▇▇▇) ▇▇▇-▇▇▇▇ I acknowledge receipt of the HMIS Notice of Privacy Practices. Client Signature Client Name Printed Date Inability to Obtain Acknowledgement To be completed only if no signature is obtained. If it is not possible to obtain the client’s acknowledgement, describe the good faith efforts made to obtain the client’s acknowledgement, and the reasons why the acknowledgement was not obtained: Staff Member’s Signature Staff Name and Title Printed Date Revs. 01/2024 The undersigned certifies, to the best of his or her knowledge and belief, that:

Right to a Paper Copy of This Notice. You may ask us for a paper copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are entitled to receive a paper copy of this Notice. To obtain a paper copy of this Notice, ask any member of staff.. You have the right to file a complaint if you believe that staff has not complied with the practices outlined in this Notice. All complaints must be submitted in writing. You will not be penalized in any way for filing a complaint. If you believe your privacy rights have been violated, you may file a complaint with the NorCal CA 516 Continuum of Care System Administrator. To file a complaint with the Administrative Entity, contact: City of ▇▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇. Redding, CA 96001 Email: ▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ To file a complaint with the State of California, contact: ▇▇▇.▇▇▇▇▇▇▇.▇▇.▇▇▇ ▇▇▇-▇▇▇-▇▇▇▇ ▇▇▇-▇▇▇-▇▇▇▇ By signing this form, you acknowledge receipt of the HMIS Notice of Privacy Practices. Our Notice of Privacy Practices provides information about how we may use and disclose your protected information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by accessing our web site, ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hmis or by contacting any staff person involved in your services. If you have any questions about our Notice of Privacy Practices, please contact: United Way of Northern California ▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ ▇▇, ▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ (▇▇▇) ▇▇▇-▇▇▇▇ I acknowledge receipt of the HMIS Notice of Privacy Practices. Client Signature Inability to Obtain Acknowledgement Client Name Printed Date Inability to Obtain Acknowledgement To be completed only if no signature is obtained. If it is not possible to obtain the client’s acknowledgement, describe the good faith efforts made to obtain the client’s acknowledgement, and the reasons why the acknowledgement was not obtained: Staff Member’s Revs. 01/2024 Signature Staff Name and Title Printed Date Revs. 01/2024 The undersigned certifies, to the best of his or her knowledge and belief, that: