HIPAA Privacy Practices Acknowledgment Form

Patient Acknowledgment

I, _______________________________ (print name), acknowledge that I have received a copy of [Practice Name]'s Notice of Privacy Practices.

I understand that this Notice describes:

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

Authorization

By signing below, I confirm that:

1. I have reviewed the Notice of Privacy Practices
2. I understand my privacy rights
3. I consent to the use of my PHI as described in the Notice

Patient Information:

Signature: _________________________________ Date: _____________________________________ Phone: ____________________________________ Email: ____________________________________

For Office Use Only

Documentation of Good Faith Effort

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 □ Communications barrier prevented obtaining acknowledgment □ Emergency situation prevented obtaining acknowledgment □ Other (specify): ____________________________

Staff Member Initials: _______ Date: _________________

This form complies with HIPAA Privacy Rule requirements