Patient Information Form - Green Valley Ranch Medical Clinic & Urgent Care Page 6

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HIPAA OMNIBUS RULE
PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM
You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.
Date: __________________
The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for
Green Valley Ranch Medical Clinic & Urgent Care (GVRMC&UC). A copy of this signed, dated document
shall be as effective as the original.
MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR
RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.
____________________________________
______________________________________________
Print name of Patient
Signature of Patient / Guardian of Patient
____________________________________
______________________________________________
Legal Representative / Guardian
Relationship of Legal Representative / Guardian
I consent to the use of my first name only in the reception area for my privacy
Yes
No
PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
(This includes step parents, grandparents and any care takers who can have access to this patient’s
records):
Name: _______________________________
Relationship: _______________________________
Name: _______________________________
Relationship: _______________________________
Name: _______________________________
Relationship: _______________________________
Your comments regarding Acknowledgements or Consents or Revocations: ___________________________________________
_______________________________________________________________________________________________________
CONSENT TO EMAIL, TEXT OR LEAVE VOICE MESSAGES FOR APPOINTMENT REMINDERS AND OTHER
HEALTHCARE COMMUNICATIONS
Patients in our practice may be contacted via email and/or text messaging or voice calls to remind you of
an appointment, to obtain feedback on your experience with our healthcare team, and to provide
general health reminders/information.
I agree to provide (on our demographics form) only the numbers and email addresses for patient that may
Yes
No
be used for the above communications.
I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH
INFO on behalf of GVRMC&UC via:
Phone Message
 Any of the Above
Text Message
 None of the above (opt out)
Email
In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or
services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies.
We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.
Office Use Only
As Privacy Officer, I attempted to obtain the patient’s (or representatives) signature on this Acknowledgement but did not because:
It was emergency treatment
_____
I could not communicate with the patient
_____
The patient refused to sign
_____
The patient was unable to sign because
_____
Other (please describe)
____
____________________________________________
Signature of Privacy Officer

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