Statement of Participation In HIPPA In-Service

I hereby certify that I have attended a HIPPA In-Service and understand the information presented. I acknowledge that I have an obligation to perform my duties in a lawful manner and consistent with the Standards of Business Conduct. I further understand that it is my duty to report violations of the law or of the Standards of Business Conduct to my Supervisor.

Today's Date (DD/MM/YYYY)  /   / 

Signature of Employee

Print Name

Email

PRN Signature

Title

After you've completed this form, please type PRN in this box * to validate this form then click the "Submit" button.