Acknowledgement Of Receipt Of Privacy Notice Form printable pdf download

Acknowledgement Of Receipt Of Privacy Notice Form

University Orthopaedic and Sports Medicine Clinic

Acknowledgement of Receipt of Privacy Notice

I have been provided with a Notice of Privacy Practices that provides me a more complete description of the

uses and disclosures of certain health information. I understand University Orthopaedic and Sports Medicine

Clinic reserves the right to change their Notice of Privacy Practices and prior to implementation will provide an

updated copy. I may request a copy of the updated Notice of Privacy Practices by calling my physician’s office

or requesting a copy in person at my appointment.

The duration of this authorization is indefinite unless otherwise revoked in writing. I understand that requests

for medical information from persons not listed above will require a specific authorization prior to disclosure

of any medical information.

Patient’s Printed Name

Date of Birth

Patient/Legal Representative Signature

Date

Relationship to Patient

Witness

Date

The following names are of people I would like to be involved in or have access to my protected health

information on a routine basis. I give permission for University Orthopaedics and Sports Medicine Clinic

to share my protected health information with:

Name

Relationship

Name

Relationship

Name

Relationship

I wish to be contacted in the following manner:

Ok to leave message with detailed information?

□

Home Phone

Yes

□

Cell Phone

Yes

□

Work Phone

Yes

Acknowledgement Of Receipt Of Privacy Notice Form