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2. 
4. Chisago County Public Health Nurse*
   -- Select One --BarbBethanyBrandieErinHeatherJenRushess
6. NAME OF INDIVIDUAL:*
8. Chisago County Health & Human Services Notice of Privacy Practive
   Please view the attached 3-page Notice of Privacy Practice
10. This is to acknowledge receipt of Chisago County Health & Human Services Notice of Privacy Practice with an effective date of:*
    This is to acknowledge receipt of Chisago County Health & Human Services Notice of Privacy Practice with an effective date of:
12. Individual's (or Legal Representative's) Name:*
14. I agree and consent to providing a digital signature.
16. Individual's (or Legal Representative's) Digital Signature:*
17. Date Signed:*
    Date Signed:
19. Capacity or Authority or Legal Representative (if applicable)**:
    **May be requested to provide verification of representative status.
23. 
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