HIPAA Privacy Practices Acknowledgment Form

Patient Information

Name: ________________________________
Date of Birth: _________________________
Medical Record Number: _________________

Acknowledgment

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:

• I have the right to review the Notice of Privacy Practices before signing this form
• The Notice of Privacy Practices may change over time, and I can obtain a current copy by contacting [Practice Name]
• I have the right to request restrictions on how my protected health information is used or disclosed
• [Practice Name] is not required to agree to requested restrictions
• I have the right to revoke this acknowledgment in writing

Signatures

Patient or Legal Representative Signature: _________________
Date: ________________

If signed by Legal Representative, Relationship to Patient: ________________

For Office Use Only

□ Patient refused to sign □ Emergency situation prevented obtaining acknowledgment □ Other: ____________________________

Staff Signature: _________________
Date: ________________

Form ID: HIPAA-OT-2023