HIPAA Privacy Practices Acknowledgment Form

Patient Information

Name: _________________________________ Date of Birth: //______ Medical Record Number: ___________________ Date: //______

Acknowledgment

I acknowledge that I have received a copy of the Notice of Privacy Practices from [Practice Name]. The Notice of Privacy Practices describes:

• How my health information may be used and disclosed
• My rights regarding my health information
• The practice's legal duties concerning my health information

Authorization for Information Release

I authorize the release of my health information to the following individuals:

1. Name: _________________________ Relationship: _________________
2. Name: _________________________ Relationship: _________________

Emergency Contact

In case of emergency, I authorize contact with: Name: _________________________ Phone: _____________________

Understanding

I understand that:

• This acknowledgment form will be kept in my medical record
• I have the right to revoke this authorization at any time in writing
• This authorization will remain in effect until revoked

Signatures

Patient/Legal Guardian Signature: ___________________ Date: //______

If signed by Legal Guardian, state relationship: ___________________

For Office Use Only

□ Patient refused to sign □ Emergency situation □ Other: _________________________

Staff Signature: _________________________ Date: //______