"Hipaa" Acknowledgement Form

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“HIPAA” Acknowledgement
I understand that under the Health Insurance Portability & Accountability Act of 1996
(“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 have received, read and understand 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 bellow to obtain
a current copy of the Notice of Private 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 acknowledgement on this Notice of
Privacy Practices Acknowledgement, but was unable to do so as documented below.
__________________________________________________________________
Date
Initials
Reason
_____________________________________________________________

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