Patient Acknowledgement Form Use & Disclosure Of Protected Health Information (Phi) (Hipaa Acknowledgement Form) printable pdf download

Patient Acknowledgement Form Use & Disclosure Of Protected Health Information (Phi) (Hipaa Acknowledgement Form)

Patient Acknowledgement Form:

Use & Disclosure of Protected Health Information (PHI)

(HIPAA Acknowledgement Form)

Heather B. Scheffler, Ph.D., has provided me with a copy of her “Notice of

Psychologists’ Policies and Practices to Protect the Privacy of Your Health

Information.” I understand that this notice describes how Dr. Scheffler and Scheffler

Psychological Associates may use and disclose protected health information (PHI) as it

pertains to my mental health treatment.

By signing this form, I consent to Dr. Scheffler’s business policies and use and

disclosure of protected health information (PHI) about me for treatment, payment, and

health care operations. I understand that I have the right to revoke this consent, in writing,

except where Dr. Scheffler has already made disclosures in trust prior to my request.

_____________________________________________________________________

________________________

Signature of parent, guardian, or authorized representative

Date

_____________________________________________________________________

________________________

Signature of patient/client

Witness

P.O. Box 1372

Pittsboro, NC 27312

Mobile/Office (919) 548-5612

Fax (919) 535-9247

Patient Acknowledgement Form Use & Disclosure Of Protected Health Information (Phi) (Hipaa Acknowledgement Form)