HIPAA Privacy Practices Acknowledgment Form

Patient Information

Name: _________________________________ Date of Birth: //______

Medical Record Number: ___________________ Date: //______

Acknowledgment

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

I understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations
• The Practice reserves the right to change the Notice of Privacy Practices
• I have the right to restrict the uses of my information
• I may revoke this consent in writing at any time
• The Practice may condition receipt of treatment upon execution of this consent

Signature

Patient or Legal Representative Signature: _______________________________

Print Name: _________________________________ Date: //______

If Legal Representative, Relationship to Patient: __________________________

For Practice Use Only

□ Patient refused to sign □ Unable to obtain signature

Staff Member Signature: _____________________________ Date: //______

Reason: _________________________________________________________