HIPAA Privacy Practices Acknowledgment Form - Geriatric Care

Geriatric Care Services

I, _______________________________ (print patient name), acknowledge that I have received a copy of the Notice of Privacy Practices from [Practice Name].

Patient Information

• Date of Birth: //____
• Medical Record Number: ________________

Acknowledgment

I understand that this Notice describes:

• How my medical information may be used and disclosed
• My rights regarding my protected health information
• The practice's legal duties concerning my health information

Authorization for Communication

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

1. Name: _________________________ Relationship: _________________ Phone: _________________________

2. Name: _________________________ Relationship: _________________ Phone: _________________________

Emergency Contact Authorization

In case of emergency or my incapacity, I authorize contact with:

Name: _________________________ Phone: _________________ Relationship to Patient: _________________

Signatures

Patient/Legal Representative Signature: _________________ Date: //____

If Legal Representative, state relationship: _________________

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: //____