HIPAA Privacy Practices Acknowledgment Form

Patient Information

Name: _______________________________ Date of Birth: ________________________

Acknowledgment of Receipt

I acknowledge that I have received a copy of [Practice Name]'s Notice of Privacy Practices. This Notice describes how my health information may be used and disclosed and how I can access this information.

I understand that:

• The practice has the right to change its Notice of Privacy Practices
• I may request a current copy of the Notice at any time
• My health information may be used for treatment, payment, and healthcare operations
• I have the right to request restrictions on how my health information is used
• I may revoke this acknowledgment in writing at any time

Protected Health Information Release Authorization

I authorize the release of my nutrition-related health information to:

• Spouse: ___________________________
• Parent(s): _________________________
• Other: ____________________________

Emergency Contact

Name: _______________________________ Relationship: _________________________ Phone: ______________________________

Signatures

Patient Signature: _____________________ Date: _______________________________

If signed by legal representative: Name: _______________________________ Relationship to Patient: ________________

For Office 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
• Communication barrier prohibited obtaining acknowledgment
• Emergency situation prevented obtaining acknowledgment
• Other (specify): ____________________

Staff Signature: ______________________ Date: ______________________________