HIPAA Privacy Practices Acknowledgment Form

Patient Information

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 [Practice Name] may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.

Understanding of Rights

I understand that:

• The practice has provided me with a copy of their current Notice of Privacy Practices
• I have the right to review the Notice prior to signing this form
• The practice reserves the right to change their Notice of Privacy Practices
• I may obtain a revised Notice of Privacy Practices by contacting the office

Authorization for Communication

I authorize [Practice Name] to communicate my protected health information to:

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

Signature

Patient/Legal Representative Signature: _________________
Date: _______________

If signed by Legal Representative, Relationship to Patient: _______________

For Office Use Only:

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

Staff Signature: _________________ Date: _______________