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 this medical practice's Notice of Privacy Practices. This Notice describes how my health information may be used and disclosed by [PRACTICE NAME] and outlines my rights regarding my health information.

Understanding of Rights

I understand that:

• The practice has the right to change its Notice of Privacy Practices
• I may request restrictions on how my health information is used or disclosed
• I have the right to revoke this consent in writing
• This consent remains valid until revoked
• The practice may condition treatment upon execution of this acknowledgment

Specific Authorizations

I specifically authorize [PRACTICE NAME] to:

• Leave messages regarding appointments on my voicemail
• Discuss my medical condition with designated family members
• Send appointment reminders via text message
• Communicate through the patient portal

Designated Individuals

I authorize discussion of my personal health information with:

1. Name: _________________ Relationship: _________ Phone: _________
2. Name: _________________ Relationship: _________ Phone: _________

Signatures

Patient Signature: _________________________ Date: __________

If signed by person other than patient:

Printed Name: ____________________________ Date: __________
Relationship to Patient: ___________________

FOR OFFICE USE ONLY

[ ] Acknowledgment received
[ ] Acknowledgment refused

Staff Initials: _______ Date: _______

Reason for refusal: _________________________________