Hipaa Release Form (Page 2 of 2) in pdf

Hipaa Release Form Page 2

Patient Receipt of HIPAA Privacy Notice

Dear Patient,

OUCH Urgent Care is committed to maintaining the integrity of your protected health information and complies

with all applicable state and federal regulations.

The federal privacy regulations of the Health Insurance Portability and Accountability Act (HIPAA) have taken

effect April 14, 2003. In support of our policy of complying with all applicable regulations, OUCH Urgent

Care provides patients the HIPAA Notice of Privacy Rights.

While not required in order to receive treatment at OUCH Urgent Care, we are obligated under federal

regulations to ask that you sign an acknowledgement of the HIPAA Privacy Notice being made available to

you.

Thank you.

Receipt of HIPAA Privacy Notice

I acknowledge the receipt of the Notice of Privacy Rights with detailed information about how OUCH Urgent

Care may use and disclose my protected health information. I understand that OUCH Urgent Care reserves the

right to change the privacy notice and that a copy of the revised notice will be made available to me.

Printed Patient Name

Signature of Patient or Parent/Guardian



Office use only: To be completed only when a patient declined to sign acknowledgement.

Check here if patient declined to sign acknowledgement

Staff Signature_______________________________________________________________

Refusal to sign acknowledgement does not prevent the patient from continuing to be treated.

To be filed in the patient’s record

OUCH Urgent Care, LLC 2016

Hipaa Release Form Page 2