HIPAA Privacy Practices Acknowledgment Form

Patient Acknowledgment

I, _______________________ (print patient name), acknowledge that I have received and reviewed 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 health information

Authorization

By signing below, I acknowledge:

1. I have been provided with the opportunity to review the Notice of Privacy Practices
2. I understand my rights as described in the Notice
3. I understand how my protected health information will be used

Signatures

Patient Signature: _______________________ Date: //___

If signed by someone other than the patient:

Representative Name: _______________________ Relationship to Patient: ____________________ Representative Signature: __________________

For Office Use Only

[ ] Patient refused to sign [ ] Emergency situation prevented obtaining acknowledgment [ ] Other: ________________________________

Staff Member Name: _______________________ Staff Signature: _________________________ Date: //___

Form ID: HIPAA-PSY-001 Revision Date: [Current Date]