Form 009893 - Hipaa - Patient Acknowledgement Form

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HIPAA - Patient Acknowledgement Form
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, but is not mandatory for me to sign
in order 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 been informed by you of your Notice of Privacy Practices containing a more
complete description of the uses and disclosures of my health information. I have been
given a copy of your Notice of Privacy Practices prior to signing this consent. I
understand that this office has the right to change its Notice of Privacy Practices from
time to time and that I may contact this office at any time at the address above to obtain a
current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is
used or disclosed to carry out, 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.
I understand that I may revoke this consent in writing at any time, except to the extent
that you have taken action relying on this consent.
Patient Name:
__________________________________________
Signature:
__________________________________________
Relationship to Patient: _____________________________________
Date:
___________________________________________

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