HIPAA Privacy Practices Acknowledgment Form for Concierge Medical Services

Patient Information

Name: _________________________ Date of Birth: _________________ Address: _______________________ Phone: _______________________

Acknowledgment of Receipt

I acknowledge that I have received a copy of [Practice Name]'s Notice of Privacy Practices. I understand that this document provides detailed information about how the practice may use and disclose my protected health information, as well as my rights as a patient under HIPAA regulations.

Special Authorizations for Concierge Services

• I understand that as a member of this concierge medical practice, my physician may need to communicate with me through various channels, including:

  • Direct cell phone communication
  • Secure text messaging
  • Email correspondence
  • Patient portal messages
  • Virtual consultations

• I authorize the following methods of communication (initial all that apply):

  • ____ Cell phone direct contact
  • ____ Text messaging
  • ____ Email
  • ____ Patient portal
  • ____ Video consultations

Additional Permissions

I authorize the practice to discuss my medical information with:

Name: _________________________ Relationship: _________________ Name: _________________________ Relationship: _________________

Signature

Patient/Legal Guardian Signature: ___________________ Date: ________

Print Name: _________________________ Relationship to Patient: ____________

For Office Use Only

We attempted to obtain written acknowledgment but could not because:

• Individual refused to sign
• Communication barrier prohibited obtaining acknowledgment
• Emergency situation prevented obtaining acknowledgment
• Other (specify): _________________________

Staff Signature: _________________________ Date: ________