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 _________________________________________________________________
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: _________________________________________