Hipaa - Patient Acknowledgement/use And Disclosure Form

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HIPAA – PATIENT ACKNOWLEDGEMENT/USE and DISCLOSURE FORM
Our Notice of Privacy Practices (NPP) provides information about how The Arrhythmia Institute may use and disclose
protected health information (PHI) about you. The practice provides this form to comply with the Health Insurance
Portability and Accountability Act (HIPAA). The NPP contains a Patient Rights section describing your rights under the law.
Please review the Notice of Privacy Practices thoroughly before signing this acknowledgement form. In the event that
terms of the Notice change, a revised copy will be made available to you.
By signing this form, you acknowledge that our Practice may use and disclose PHI about you for treatment, payment and
healthcare operations. You have the right to request that we restrict how PHI about you is used or disclosed for
treatment, payment or healthcare operations.
I have received the Notice of Privacy Practices.
Signature of Patient or Legally Authorized Representative
Date of Birth
Date
Printed Name of Patient or Legally Authorized Representative
Legal Relationship to Patient
I give permission for The Arrhythmia Institute to:
Leave a message: call back/contact information only
(phone/text#)
(email)
Leave a message: appointment information/time
(phone/text#)
(email)
Leave a message: detailed medical info/test results
(phone/text#)
(email)
I give permission for The Arrhythmia Institute to share medical information with:
1- Name
Relationship
(Phone #)
2- Name
Relationship
(Phone #)
I assume responsibility to inform the practice of any changes in the above information.
Print Patient’s Name
Date
Patient’s Date of Birth
Relationship to Patient (if not patient)
Signature
Today’s Date

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