HIPAA Privacy Practices Acknowledgment Form

Patient Information

Name: _________________________ Date of Birth: _____________ Chart Number: ___________________ Date: _____________________

Acknowledgment

I acknowledge that I have received and reviewed a copy of [Practice Name]'s Notice of Privacy Practices, which describes:

• How my health information may be used and disclosed
• My rights regarding my protected health information
• The practice's legal duties concerning my health information

Understanding

I understand that:

1. The practice has the right to change its Notice of Privacy Practices
2. I may obtain a current copy by contacting the practice's Privacy Officer
3. I may request restrictions on how my information is used
4. This acknowledgment is valid until revoked by me in writing

Authorization for Information Release

I authorize the release of my protected health information to:

Name: _________________________ Relationship: ______________ Name: _________________________ Relationship: ______________

Signature

Patient/Legal Guardian: _____________________ Date: _________

For Office Use Only

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

Staff Signature: ________________________ Date: ____________