Hipaa Privacy Rule Receipt Of Notice Of Privacy Practices Acknowledgement Form printable pdf download

Hipaa Privacy Rule Receipt Of Notice Of Privacy Practices Acknowledgement Form

HIPAA Privacy Rule Receipt of Notice of Privacy Practices Acknowledgement Form

I,_______________________________ (Patient’s Name) understand that as part of my health care, this facility

originates and maintains health records describing my health history, symptoms, examination and test results,

diagnosis, treatment and any plans for future care or treatment. I acknowledge that I have been provided with

and understand that this facility’s Notice of Privacy Practices provides a complete description of the uses and

disclosures of my health information. I understand that:

 I have the right to review the facility’s Notice of Privacy Practices prior to signing this

acknowledgement

 This facility reserves the right to change their Notice of Privacy Practices and prior to implementation of

this will mail a copy of any revised notice to the address I've provided if requested.

__________________________________________________________

_____________________________

Printed Name of Patient/Legal Representative

Relationship to patient

_______________________________________________________

________________________________

Signature of Patient or Legal Representative

Date

FOR OFFICE USE ONLY

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

Individual refused to sign

Communication barrier prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Others (please specify):________________________________________________________________________________

_________________________________________________________________

__________________________

Office Staff Signature

Date

StatCare Minor Emergency Clinic Notice of Privacy Practices

-5-

Hipaa Privacy Rule Receipt Of Notice Of Privacy Practices Acknowledgement Form