HIPAA Notice of Privacy Practices Acknowledgment Form

Patient Acknowledgment

I, _________________________________ [print 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:

• My health information may be used for treatment, payment, and healthcare operations
• I have the right to request restrictions on how my information is used
• I have the right to receive confidential communications
• I have the right to inspect and copy my health record
• I have the right to request amendments to my health record
• I have the right to receive an accounting of disclosures of my health information
• I have the right to receive a paper copy of the Notice of Privacy Practices

Signatures

Patient Signature: _____________________________ Date: _______________

If signed by person other than patient, print name and state relationship:

Name: _____________________________ Relationship: _______________

For Practice Use Only

___ Patient refused to sign ___ Communication barriers prohibited obtaining acknowledgment ___ Emergency situation prevented obtaining acknowledgment ___ Other (specify): ________________________________________

Staff Signature: _____________________________ Date: _______________