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 my health information may be used and disclosed and how I can access this information.

Understanding of Rights

I understand that:

• I have the right to review the Notice of Privacy Practices before signing this form
• The Practice may change the Notice of Privacy Practices at any time
• I may obtain a current copy of the Notice of Privacy Practices by contacting the Practice
• I have the right to request restrictions on how my health information is used or disclosed
• The Practice is not required to agree to my requested restrictions
• I may revoke this consent in writing at any time

Authorization

Patient/Legal Representative Signature: _______________________ Printed Name: ___________________________________________ Relationship to Patient (if applicable): _________________________

For Practice Use Only

☐ Patient refused to sign ☐ Emergency situation prevented obtaining acknowledgment ☐ Other: _______________________________________________

Staff Member Signature: ___________________________________ Date: _________________________________________________

This document is to be retained in the patient's medical record