HIPAA Notice of Privacy Practices Acknowledgment Form

[Practice Name] [Address] [City, State ZIP] [Phone]

Acknowledgment of Receipt

I acknowledge that I have received a copy of [Practice Name]'s Notice of Privacy Practices. I understand that this document provides an explanation of the ways in which my health information may be used and disclosed by [Practice Name] and of my rights with respect to my health information.

Patient Information

• Patient Name (printed): ________________________________
• Date of Birth: //______

Signature

Patient or Personal Representative Signature

Date

If Signed by Personal Representative

• Representative's Name (printed): ________________________________
• Relationship to Patient: ________________________________

For Office Use Only

Documentation of Good Faith Effort

Attempt was made to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because:

□ Individual refused to sign □ Communications barriers prohibited obtaining the acknowledgment □ An emergency situation prevented us from obtaining acknowledgment □ Other (Please specify): ________________________________

Staff Member Signature

Date