Please Sign and Date this form and return to the Board office at:

 

Shelby County Board of MR/DD

Kristi L. Marcum, Business Manager

1200 S. Children’s Home Road

P.O. Box  925

Sidney, OH  45365

 

 

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Acknowledgement of Receipt of Privacy Notice

 

 

I have received a copy of the Privacy Notice from the Shelby County Board of MR/DD.

 

 

 

Enrollee’s Name  ________________________________________________________

 

 

 

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          Signature of Individual Receiving Notice                                         Date