Patient Hipaa Acknowledgement And Designation Disclosure Form
ADVERTISEMENT
1
2PATIENT HIPAA ACKNOWLEDGEMENT AND DESIGNATION
DISCLOSURE FORM
Acknowledgement of Practice’s Notice of Privacy Practices:
I.
By subscribing my name below, I acknowledge that I was provided a copy of the Notice of Privacy
Practices (NPP), and that I have read (or had the opportunity to read if I so chose) and understand the
Notice of Privacy Practices (NPP) and agree to its terms.
Name of Patient
Date of Birth
Signature of Patient/Parent/Guardian
Date
II.
Designation of Certain Relatives, Close Friends and other Caregivers as my Personal
Representative:
I agree that the practice may disclose certain pieces of my health information to a Personal
Representative of my choosing, since such person is involved with my healthcare or payment
relating to my healthcare. In that case, the Physician Practice will disclose only information that is
directly relevant to the person’s involvement with my healthcare or payment relating to my health
care.
Print Name:
Last four digits of SSN or other identifier:
Print Name:
Last four digits of SSN or other identifier:
Print Name:
Last four digits of SSN or other identifier:
III.
Request to Receive Confidential Communications by Alternative Means:
As provided by Privacy Rule Section 164.522(b), I hereby request that the Practice make all
communications to me by the alternative means that I have listed below.
Home Telephone Number:
Written Communication Address:
OK to leave message with detailed information
OK to mail to address listed above
Leave message with call back numbers only
E-mail me at:
Work Telephone Number:
Fax Communication:
OK to leave message with detailed information
OK to Fax at the number listed above
Leave message with call back numbers only
E-mail me at:
Other:
are not authorized
IV.
The following person(s)
to receive my Patient Health Information (PHI):
Print Name:
Print Name:
Print Name:
Print Name:
V.
The HIPAA Privacy rule requires healthcare providers to take reasonable steps to limit the use
or disclosure of, and requests for PHI. I understand that this accounting will not reflect disclosures
that are made in the course of the Practice’s ordinary health care activities related to providing
patient treatment, obtaining payment for its services or its internal operations. Also, the Practice
does not have to account for disclosures for which I have executed an Authorization permitting
disclosures of my PHI.
Date of
Disclosed to whom:
Description of
Purpose of
Dates of
Person
Date
disclosure
address/fax
disclosure
disclosure
Service of
completing
completed
request
disclosure
request
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical