HIPAA Privacy Acknowledgment Form for Cardiac Surgery

Department of Cardiac Surgery

I, _________________________ (print patient name), acknowledge that I have received a copy of the Notice of Privacy Practices from [HOSPITAL/PRACTICE NAME]'s Department of Cardiac Surgery.

Understanding of Rights

By signing this form, I understand that:

• My personal health information may be used and disclosed for treatment, payment, and healthcare operations
• I have the right to review the Notice of Privacy Practices before signing this acknowledgment
• The practice reserves the right to change their privacy practices as described in the Notice
• I have the right to request restrictions on how my health information is used
• I may revoke this consent in writing, except for actions already taken

Specific Authorizations

I specifically authorize the cardiac surgery team to:

1. Leave detailed messages regarding appointments and cardiac test results on my voicemail at: ________________
2. Discuss my medical condition with the following individuals:
   • Name: _________________ Relationship: ________________
   • Name: _________________ Relationship: ________________

Signatures

Patient Signature: _________________________ Date: ___________

If signed by person other than patient:

Name: _________________________ Relationship: _____________

For Office Use Only:

□ Patient refused to sign □ Emergency situation □ Unable to communicate

Staff Signature: _________________________ Date: ___________