HIPAA Privacy Practices Acknowledgment Form

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ________________

Acknowledgment of Receipt

I acknowledge that I have received a copy of [Practice Name]'s Notice of Privacy Practices. This Notice describes how [Practice Name] may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.

Understanding of Rights

I understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations
• The Practice has a Notice of Privacy Practices and I have the opportunity to review this Notice
• The Practice reserves the right to change the Notice of Privacy Practices
• I have the right to restrict the uses of my protected health information
• I may revoke this consent in writing at any time
• The Practice may condition receipt of treatment upon execution of this consent

Signatures

Patient or Legal Representative Signature: _____________________ Date: _____________

Print Name: _____________________ Relationship to Patient (if applicable): _____________________

For Practice Use Only

We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but it could not be obtained because:

□ Individual refused to sign □ Communications barrier prevented obtaining acknowledgment □ An emergency situation prevented us from obtaining acknowledgment □ Other (Please specify): _____________________

Staff Signature: _____________________ Date: _____________