HIPAA Privacy Practices Acknowledgment Form

Patient Acknowledgment of Receipt

I, _________________________________ (print name), acknowledge that I have received a copy of [Practice Name]'s Notice of Privacy Practices.

Understanding of Rights

I understand that this document informs me of:

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

Authorization for Communication

I authorize [Practice Name] to communicate about my medical/dental condition and treatment with:

1. Name: _____________________ Relationship: _____________ Phone: _______________
2. Name: _____________________ Relationship: _____________ Phone: _______________

Preferred Contact Methods

Please indicate your approved contact methods:

□ Home Phone: ________________ □ Cell Phone: ________________ □ Work Phone: ________________ □ Email: ____________________ □ Text Message

Signature Section

Patient/Legal Guardian Signature: _______________________ Date: _______________

For Office Use Only

□ Patient refused to sign □ Unable to obtain signature

Staff Signature: ________________________ Date: _______________

This acknowledgment form becomes part of your permanent medical record.