HIPAA Privacy Practices Acknowledgment Form - Pediatric Practice

Patient Information

Child's Name: _____________________________ Date of Birth: _______________ Parent/Legal Guardian Name: ___________________________________________

Acknowledgment

I acknowledge that I have received a copy of [Practice Name]'s Notice of Privacy Practices, which describes how medical information about my child may be used and disclosed and how I can get access to this information.

Understanding of Rights

• I understand that I have the right to review the Notice prior to signing this acknowledgment
• I understand that the organization reserves the right to change their Notice and practices
• I understand that I have the right to request restrictions on how my child's protected health information is used or disclosed for treatment, payment, or healthcare operations
• I understand that the organization is not required to agree to my requested restrictions

Authorization for Information Sharing

I authorize [Practice Name] to share my child's protected health information with:

1. Name: _________________________ Relationship: _________________
2. Name: _________________________ Relationship: _________________

Signatures

Parent/Legal Guardian Signature: ______________________ Date: __________

Print Name: ______________________________

For Office Use Only

We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but it could not be obtained because:

□ Individual refused to sign □ Communications barrier prohibited obtaining acknowledgment □ Emergency situation prevented us from obtaining acknowledgment □ Other (specify): ____________________________

Staff Signature: ________________________ Date: __________