HIPAA Privacy Practices Acknowledgment Form

Patient Information

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

Acknowledgment of Notice

I acknowledge that I have received a copy of [Practice Name]'s Notice of Privacy Practices. I understand that this document provides information about how my health information may be used and disclosed.

Authorization for Communication

I authorize [Practice Name] to communicate my protected health information to:

• Leave detailed messages on voicemail: □ Yes □ No
• Share information with family members: □ Yes □ No

Authorized individuals:

1. Name: _____________________ Relationship: ___________________
2. Name: _____________________ Relationship: ___________________

Electronic Communication Consent

I consent to receive communications via:

• Email: □ Yes □ No
• Text message: □ Yes □ No
• Patient Portal: □ Yes □ No

Understanding of Rights

I understand that:

• I have the right to revoke this authorization at any time
• My treatment is not conditional upon signing this acknowledgment
• I may request restrictions on use/disclosure of my information

Patient/Guardian Signature Date

Witness Signature Date

For Office Use Only

Attempt to obtain acknowledgment was unsuccessful because: □ Patient refused □ Emergency situation □ Other: ____________________

Staff Initials: _____ Date: _____