HIPAA Privacy Notice Acknowledgment Form

Patient Information

Full Name: ________________________________
Date of Birth: //_____
Medical Record Number: ___________________

Acknowledgment of Receipt

I acknowledge that I have received a copy of [Practice Name]'s Notice of Privacy Practices. This Notice describes how my health information may be used or disclosed. I understand that I should read it carefully.

I am aware that the Notice may be changed at any time. I may obtain a revised copy of the Notice by contacting the practice's Privacy Officer at [contact information].

Additional Permissions

I authorize [Practice Name] to disclose my protected health information to the following individuals:

1. Name: _______________________________
   Relationship: _________________________
   Phone: ______________________________

2. Name: _______________________________
   Relationship: _________________________
   Phone: ______________________________

Communication Preferences

I authorize [Practice Name] to contact me in the following ways (check all that apply):

□ Home Phone: ________________________
□ Cell Phone: _________________________
□ Work Phone: ________________________
□ Email: _____________________________
□ Text Message

Signature

Patient/Legal Representative: _____________________
Date: //_____

If Legal Representative, relationship to patient: ________________

FOR OFFICE USE ONLY

We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but it could not be obtained because:

□ Individual refused to sign
□ Communication barrier prohibited obtaining acknowledgment
□ Emergency situation prevented us from obtaining acknowledgment
□ Other (specify): ________________________

Staff Member Initials: _______ Date: //_____