HIPAA Privacy Practices Acknowledgment Form

Patient Acknowledgment of Receipt of Notice of Privacy Practices

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

Understanding of Rights

I understand that:

• My protected health information may be used and disclosed to carry out treatment, payment, or healthcare operations
• The practice reserves the right to change the Notice of Privacy Practices
• I have the right to restrict how my protected health information is used and disclosed
• I may revoke this consent at any time by making a request in writing

Authorization for Communication

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

• Phone calls to: _______________________
• Voice messages at: ____________________
• Text messages to: _____________________
• Email at: ____________________________

Emergency Contact Authorization

I authorize the disclosure of my protected health information to:

Name: _______________________ Relationship: _________________ Phone: ______________________

Patient Signature Date

Guardian Signature (if applicable) Date

FOR OFFICE USE ONLY

[ ] Patient refused to sign [ ] Communication barriers prohibited obtaining acknowledgment [ ] Emergency situation prevented obtaining acknowledgment [ ] Other: ____________________

Staff Signature: _________________ Date: ______________