Notice Of Privacy Practices Acknowledgement Form printable pdf download

Notice Of Privacy Practices Acknowledgement Form

Notice of Privacy Practices Acknowledgement Form

Tamalpais Internal Medicine

23 Reed Blvd., Ste 120

Mill Valley, CA 94941

I understand that, under the Health Insurance Portability & Accountability Act of 1998 (“HIPAA”), I have

certain rights to privacy regarding my protected health information. I understand that this information can and

will be used to:

 Conduct, plan and direct my treatment and follow up among the multiple healthcare providers who may

be involved in that treatment directly and indirectly.

 Obtain payment from third-party payers.

 Conduct normal healthcare operations such as quality assessments and physician certifications.

I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of

the uses and disclosures of my health information. I understand that this organization has the right to change its

Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address

above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to

carry out treatment, payment or health care operations. I also understand you are not required to agree to my

requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Patient Name _________________________________________________________________________

Relationship to Patient _________________________________________________________________

Signature ____________________________________________________________________________

Date _________________________

OFFICE USE ONLY

I attempted to obtain the patient’s signature in acknowledgment on the Notice of Privacy

Practices Acknowledgment, but was unable to do so as documented below:

Date: ____________ Initials: _____________ Reason: _________________________________________

Notice Of Privacy Practices Acknowledgement Form