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.

I understand that this document provides detailed information about how the practice may use and disclose my protected health information, as well as my rights as a patient under HIPAA regulations.

Understanding of Rights

I understand that:

• The practice has a comprehensive Notice of Privacy Practices that I have the right to review
• Protected health information may be used for treatment, payment, and healthcare operations
• The practice reserves the right to change the Notice of Privacy Practices
• I may request restrictions on how my health information is used or disclosed
• I may revoke this consent in writing at any time

Authorization

By signing below, I acknowledge:

1. Receipt of the Notice of Privacy Practices
2. Understanding of my rights under HIPAA
3. Consent to use my information as outlined in the Notice

Patient Signature

Date

Legal Representative (if applicable)

Relationship to Patient

For Office Use Only

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

Staff Signature: _______________ Date: _______________