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, which describes how my protected health information (PHI) may be used and disclosed in accordance with HIPAA regulations.

Authorization for Information Sharing

I understand that my oncology care team may need to:

• Share my medical information with other healthcare providers
• Coordinate treatment plans with specialists
• Communicate with insurance providers
• Contact me regarding appointments and treatment protocols

Special Authorizations

I specifically authorize the following (initial each):

____ Discussion of my medical condition with designated family members/friends ____ Leaving detailed messages on my voicemail regarding: - Test results - Treatment schedules - Medication instructions

Designated Contacts

Name: _________________ Relationship: _________ Phone: _________ Name: _________________ Relationship: _________ Phone: _________

Signature

Patient/Legal Representative: _____________________ Date: ________________

If Legal Representative, state relationship: ______________

For Office Use Only

□ Patient refused to sign □ Emergency situation prevented acknowledgment □ Other: ___________________________

Staff Signature: _________________ Date: _________