HIPAA Notice of Privacy Practices Acknowledgment Form

Patient Acknowledgment

I, _________________________________ (print patient name), acknowledge that I have received and reviewed a copy of [Clinic Name]'s Notice of Privacy Practices.

I understand that this Notice describes:

• How my medical information may be used and disclosed
• My rights regarding my protected health information
• The clinic's legal duties concerning my health information

Authorization for Information Sharing

I authorize [Clinic Name] to share my protected health information with:

1. Name: _____________________ Relationship: ___________________ Phone: _____________________

2. Name: _____________________ Relationship: ___________________ Phone: _____________________

Understanding of Rights

I understand that:

• I have the right to revoke this authorization at any time in writing
• This authorization will remain in effect until revoked
• Treatment is not conditional upon signing this acknowledgment

Signatures

Patient/Legal Guardian Signature: _______________________________

Date: //____

If signed by someone other than patient, state relationship: _______________

FOR OFFICE USE ONLY

□ Patient refused to sign □ Emergency situation □ Other: ____________________

Staff Signature: _________________ Date: //____