HIPAA Privacy Acknowledgment and Consent Form

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Acknowledgment of Privacy Practices

I understand that under the Health Insurance Portability and Accountability Act (HIPAA), I have certain rights to privacy regarding my protected health information. I acknowledge that I have received or have been given the opportunity to receive a copy of your Notice of Privacy Practices. I understand that this information can and will be used to:

• Conduct, plan, and direct my treatment and follow-up care among the healthcare providers who may be involved in my treatment directly or indirectly
• Obtain payment from third-party payers
• Conduct normal healthcare operations such as quality assessments and physician certifications

Authorization for Release of Information

I authorize the release of my protected health information including clinical records, to the following individuals:

1. Name: _________________ Relationship: _____________ Phone: _____________
2. Name: _________________ Relationship: _____________ Phone: _____________

Communication Preferences

I authorize the practice to contact me in the following ways (check all that apply):

□ Home Phone □ Cell Phone □ Work Phone □ Email □ Text Message

Photography Consent

I consent to the taking of photographs and/or video footage for treatment planning and documentation purposes. These images:

• Will become part of my medical record
• May be used for surgical planning and documentation
• Will not be used for marketing without additional explicit consent

Signature

Patient/Guardian Signature: _________________ Date: _____________

Print Name: _________________ Relationship to Patient: _____________

For Office Use Only: Received by: _________________ Date: _____________