HIPAA Privacy Practices Acknowledgment Form

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record Number: __________ Date: _____________________

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 the right to change their Notice of Privacy Practices
• I may request restrictions on how my information is used or disclosed
• I may revoke this consent in writing at any time
• The practice may condition treatment upon execution of this acknowledgment

Authorization for Information Sharing

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

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

Signatures

Patient Signature: _________________ Date: _________________

If applicable: Legal Representative: ______________ Relationship: __________

For Office Use Only

□ Patient refused to sign □ Emergency situation prevented obtaining acknowledgment □ Other: _________________________

Staff Signature: __________________ Date: _________________