HIPAA Privacy Practices Acknowledgment Form

Patient Information

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

Acknowledgment of Notice of Privacy Practices

I acknowledge that I have received and reviewed a copy of [Practice Name]'s Notice of Privacy Practices, which explains:

• How this endocrinology practice may use and disclose my protected health information
• My privacy rights regarding my protected health information
• The practice's obligations concerning the use and disclosure of my protected health information

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: _________________
• Patient Portal

Authorization for Information Sharing

I authorize the release of my medical information to the following individuals:

1. Name: _________________ Relationship: _________________ Phone: _________________
2. Name: _________________ Relationship: _________________ Phone: _________________

Signature

Patient/Legal Guardian Signature: _________________ Date: _________________

Print Name: _________________ Relationship to Patient: _________________

For Office Use Only

We attempted to obtain written acknowledgment but it could not be obtained because:

• Individual refused to sign
• Communication barrier prohibited obtaining acknowledgment
• Emergency situation prevented obtaining acknowledgment
• Other: _________________

Staff Signature: _________________ Date: _________________