background shadows

NJ DCF Logo with reverse copy

 

New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date: 4-22-2003

Volume:

X

Forms

Chapter:

A

Forms

Revised Date: 6-17-2019

Subchapter:

1

Forms

Issuance:

11.50

CP&P Form 11-50, Acknowledgment of Receipt of Notice of Privacy Practices

 

Click here to view on-line or print out a blank CP&P Form 11-50, Acknowledgement of Receipt of Notice of Privacy Practices.

 

Click here to view or print this form in Arabic, 11-50(A).

Click here to view or print this form in Brazilian Portuguese, 11-50(BP).

Click here to view or print this form in Creole, 11-50(C).

Click here to view or print this form in Dutch, 11-50(D).

Click here to view or print this form in French Creole, 11-50(FC).

Click here to view or print this form in German, 11-50(G).

Click here to view or print this form in Portuguese, 11-50(P).

Click here to view or print this form in Russian, 11-50(R).

Click here to view or print this form in Spanish, 11-50(S).

 

                                                                                                                                   

PURPOSE AND USE

 

The Acknowledgement of Receipt of Notice of Privacy Practices, CP&P Form 11-50, serves as:

 

·         A written receipt, to document that an individual was given, and signed for, a Notice of Privacy Practices (Department of Children and Families form number HIPAA 1.A.1); 

·         Written documentation that a Notice of Privacy Practices (NPP) was mailed to, or left at, a private residence (when providing an NPP in-person was impractical or not possible); and/or

·         Written documentation that a Notice of Privacy Practices was offered to a client, direct service provider or other individual but he, she or they refused to sign for it.

·         CP&P adult clients, direct service providers, as well as other individuals for whom CP&P receives protected health information (PHI) are asked to sign CP&P Form 11-50 to acknowledge that CP&P provided a Notice of Privacy Practices, HIPAA 1.A.1, to them, in compliance with HIPAA requirements.

Note: This form, and its instructions, pertains to CP&P practice, policy and procedures only. Other Divisions, Commissions and Offices within the Department of Children and Families have developed their own forms for use by their respective staffs.

 

DEFINITIONS

 

·          "HIPAA" means the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, and regulations promulgated by the United States Department of Health and Human Services, 45 CFR Parts 160 and 164, Federal legislation enacted to establish national standards for privacy and security in the handling of health-related information.

·          "Notice of Privacy Practices" ("NPP") means a form, developed by a covered entity, to advise its clients and others of their confidentiality rights under HIPAA.  In New Jersey, the NPP is a Department of Children and Families form, approved by the Attorney General's Office for use by the Divisions and agencies which comprise DCF.  (The Department assigned the NPP form number HIPAA 1.A.1.)

·          "Covered Entity" means any health care provider, health plan, or health care clearinghouse that electronically transmits health information.  The New Jersey Department of Children and Families is a covered entity.  (Each Division, Commission or Office, as a component of the Department, is required to develop its own privacy policies and procedures in compliance.  The Office of Education is an exception, and, as such, must be treated as outside the Department for HIPAA purposes.)

·          "Protected Health Information" (PHI) means individually identifiable health information gathered or received by a covered entity.  PHI includes oral, written and electronic health information about an individual that is stored or transmitted.

INSTRUCTIONS FOR COMPLETING THE FORM

 

GENERAL INSTRUCTIONS

 

The form is signed and dated by the CP&P Worker (or other CP&P representative) and the client, direct service provider or other individual for whom CP&P receives PHI.  When providing an NPP, the Worker/CP&P representative should be prepared to answer questions about the notice, CP&P handling of health information, the HIPAA law, etc.  If the Worker has any questions he or she should seek input from a Supervisor or, if necessary, the local office Liaison to the Division's Privacy Officer.

 

The receipt, CP&P Form 11-50, is signed and dated by each person for whom CP&P receives PHI, including adult clients (parents, legal guardians, etc.), children (whether living at home or in out-of-home placement), and direct service providers, including, but not limited to, substitute care providers in home-like settings (foster parents, adoptive parents, relative caregivers, etc.).

 

More than one individual can sign a single receipt associated with a given case identification number or Vendor number.  (Space is provided for up to two names and two signatures on the form.)  Minor children do not need to sign a receipt; a parent or legal guardian is the only person who can sign on behalf of a child.  Aging-out clients (youth, over age 18 continuing in active case status) must be given an NPP and asked to sign for it.  If a parent (an adult client) resides outside of the household, CP&P provides a separate notice (with a receipt) to him or her (by mail, if necessary).

 

If a Worker is not able to provide an NPP in person, he or she should discuss with the Supervisor whether to mail the NPP.  If mailing is the method agreed upon, follow the "Specific Instructions" at Scenario 2 (see below).  When mailing an NPP or leaving it at a client home, the Worker is required to make follow up efforts to obtain the client's signature on the receipt, CP&P Form 11-50.

 

The NPP and its receipt form are available in both English and Spanish versions.

 

SPECIFIC INSTRUCTIONS

 

1.   Complete CP&P Form 11-50 when a Notice of Privacy Practices is given in-person, as follows:

·         The Worker/CP&P representative or client/direct service provider/other individual for whom CP&P receives PHI enters his or her name on the first line of the form.  Up to two names can be entered. 

·         The client/direct service provider/other individual for whom CP&P receives PHI signs his or her name in the space provided.  (Up to two individuals may sign.)

·         The client/direct service provider/other individual enters the date of the signing in the space(s) provided.

·         The Worker/CP&P representative signs his or her name in the designated space.

·         The Worker/CP&P representative enters the date of his or her signing in the space provided.

·         The Worker/CP&P representative enters the case identification number or Vendor ID number, as applicable.

·         The Worker/CP&P representative enters a check mark to indicate the NPP was provided "in person."

·         The Worker/CP&P representative enters the "date" the NPP was provided in person in the space provided.

No additional information need be entered onto the form.

 

1.    File the completed receipt in the health information section of the child's case record or in the foster/adoptive home record or other CP&P file, as applicable.  Provide a copy of the signed receipt to the signer(s), upon request.

 

Make an entry in a Contact Sheet, CP&P Form 26-52, to document that the NPP was provided, and an Acknowledgment of Receipt, CP&P Form 11-50, was signed.  Print out and file the Contact Sheet in the case record.

 

2.    The Worker/CP&P representative completes CP&P Form 11-50 when a Notice of Privacy Practices is mailed, as follows:

 

·         Enter the name of the client/direct service provider/other individual for whom CP&P receives PHI on the first line of the form.  Enter up to two names.

·         Leave the two "signature" and corresponding "date" spaces blank.

·         Sign his or her name above "Worker's/CP&P Representative's Signature."

·         Enter the date of his or her signing opposite the signature.

·         Enter the case identification number or Vendor ID number, as applicable.

·         Enter a check mark to indicate that the Notice (NPP) was provided "by mail."

·         Enter the "date" the NPP was mailed in the space provided.

·         Enter details at "explain," if helpful.  (Example: "NPP sent to last known address of father.")

·         Attach the Acknowledgement of Receipt of Notice of Privacy Practices, CP&P Form 11-50, to a Notice of Privacy Practices (Department of Children and Families form number HIPAA 1.A.1).

·         Attach a self-addressed envelope to the NPP/receipt.  Enter the Worker's/CP&P representative's name and LO address on the envelope.

Make a photocopy of the CP&P Form 11-50.  File it in the health information section of the child's case record or in the foster/adoptive home record or other CP&P file, as applicable, to document that the NPP was mailed.

 

Make an entry in a Contact Sheet, CP&P Form 26-52, to document that the NPP was mailed.

 

When the signed receipt is later received, attach it to the photocopy.  File both copies of CP&P Form 11-50 in the health information section of the child's case record or in the foster/adoptive home record or other CP&P file, as applicable.

 

If the NPP/receipt is returned as undeliverable by mail, file the forms and envelope in the case record to document efforts by CP&P to provide the NPP.  Take action, as appropriate, to locate the client family.  Take further action, as appropriate, to provide the NPP to the client and obtain his or her signature on the receipt.

 

Note:  The Worker (or other CP&P representative responsible for handling the NPP) is required to make follow up efforts to obtain the client's/direct service provider's/other individual's signature on the receipt, CP&P Form 11-50.  CP&P is mandated to provide an NPP to its clients and other individuals for whom it receives protected health information, and to make concerted efforts to obtain a signed receipt to verify such provision.

 

3.    The Worker/CP&P representative completes CP&P Form 11-50 when a Notice of Privacy Practices is left at a client home/personal residence, as follows:

 

·         Enter the name of the client/direct service provider/other individual on the first line of the form.  Enter up to two names.

·         Leave the two "signature" and corresponding "date" spaces blank.

·         Sign his or her name above "Worker's/CP&P Representative's Signature."

·         Enter the date of his or her signing opposite the signature.

·         Enter the case identification number, or Vendor ID number, if known/assigned.

·         Enter a check mark to indicate that the Notice (NPP) was provided by "other" means.

·         Enter the "date" the NPP was left at the residence in the space provided.

·         Enter details at "explain."  (Example:  "Client not home.  NPP left under front door.")

·         Attach the Acknowledgement of Receipt of Notice of Privacy Practices, CP&P Form 11-50, to a Notice of Privacy Practices (Department of Children and Families form number HIPAA 1.A.1).

·         Attach a self-addressed envelope to the NPP/receipt.  The Worker/CP&P representative enters his or her name and the LO address on the envelope.  Leave a note to explain that the receipt is to be signed, dated, and returned to CP&P.

 

Make an entry in a Contact Sheet, CP&P Form 26-52, to document how the NPP was provided.

 

When the signed receipt is later received (or retrieved by staff), attach it to the photocopy.  File both copies of CP&P Form 11-50 in the health information section of the child's case record or in the foster/adoptive home record or other CP&P file, as applicable

 

Note:  The Worker (or other CP&P representative responsible for handling the NPP) is required to make follow up efforts to obtain the client's/direct service provider's/other individual's signature on the receipt, CP&P Form 11-50.  CP&P is mandated to provide an NPP to its clients and other individuals for whom it receives protected health information, and to make concerted efforts to obtain a signed receipt to verify such provision.

 

4.    The Worker/CP&P representative completes CP&P Form 11-50 when a client or other individual refuses to sign CP&P Form 11-50 as follows:

 

·         Enter the name of the client/direct service provider/other individual on the first line of the form.  Enter up to two names.

·         Leave the two "signature" and corresponding "date" spaces blank.

·         Sign his or her name above "Worker's/CP&P Representative's Signature."

·         Enter the date of his or her signing in the "date" line opposite the signature.

·         Enter the case identification number, or Vendor ID number, if known/assigned.

·         Enter a check mark to indicate how the Notice (NPP) was provided (or how provision of the NPP was attempted, but refused) - either by "other" means, or "in person."

·         Enter details at "explain."  (Example:  "During investigation, an NPP was offered to the mother.  She refused to sign for it, and tore the notice in half.")

·         Retain the CP&P Form 11-50.  File it in the health information section of the child's case record or in another CP&P file, as appropriate.

Make an entry in a Contact Sheet, CP&P Form 26-52, to document that the NPP was provided to the client, direct service provider or other individual, but he, she or they refused to sign CP&P Form 11-50 to acknowledge receipt of it.

 

 

FORM AVAILABILITY

 

CP&P Form 11-50 is available for viewing on-line, and can be printed from the on-line Forms Manual.  It is also stocked at local offices; forms can be ordered from the Forms Unit in the usual manner.

 

 

DISTRIBUTION

 

Original

-

Once signed, file in the health information section of the child's case record, or in the foster/adoptive home record or other file maintained by CP&P, as applicable.

Photocopy

-

File in the health information section of the child's case record, or in the foster home or adoptive home record or other file maintained by CP&P, as applicable (when processing an uncompleted form).  Attach to the original, when the original is signed and returned to CP&P.

Photocopy

-

Provide to the signer of CP&P Form 11-50, upon request - the client, direct service provider or other individual for whom CP&P receives PHI.

Photocopy

-

Provide to the Area Office Contract Administration Unit, responsible for the contract (for Contracted Agency homes).

Photocopy

-

Provided to the Contracted Agency, which oversees the contract foster home.