HIPAA Notice of Privacy Practices Acknowledgment Form

Patient Acknowledgment

I, _______________________________ (print patient name), acknowledge that I have received a copy of [Practice Name]'s Notice of Privacy Practices. This Notice describes how [Practice Name] may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.

Understanding of Rights

I understand that:

• [Practice Name] has provided me with a copy of their current Notice of Privacy Practices
• I may request a copy of this notice at any time
• I may view this notice electronically on the practice website at [website]
• I may request restrictions on how my information is used or disclosed
• The practice reserves the right to change the Notice of Privacy Practices

Signatures

Patient or Legal Representative Signature: _______________________________

Date: _______________

If signed by Legal Representative, Relationship to Patient: ________________

For Office Use Only

□ Patient refused to sign □ Emergency situation prevented obtaining acknowledgment □ Other: ____________________________

Staff Member Signature: _______________________________

Date: _______________

Document Control

Form Version: 1.0 Last Updated: [Date] Review Frequency: Annual