Acknowledgement Form Of Receipt Of Notice Of Privacy Practices printable pdf download

Acknowledgement Form Of Receipt Of Notice Of Privacy Practices

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Notice to Patient;

We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may

use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice.

You may refuse to sign this acknowledgement, if you wish.

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I acknowledge that I have received a copy of this office's Notice of Privacy Practices.

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Please print your name here

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Signature

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Date

We cannot discuss your protected health information (PHI) with anyone other than yourself unless you authorize us to do

so. Please list below names(s) of the individual(s) you authorize our office to discuss

care with. Your PHI maybe disclosed to the individual(s) listed below until you notify us otherwise in writing.

_________________________________

__________________________________

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FOR OFFICE USE ONLY

We have made every effort to obtain written acknowledgment of receipt of our Notice of Privacy from this patient but it

could not be obtained because:

The patient refused to sign.

Due to an emergency situation it was not possible to obtain an acknowledgement.

We weren't able to communicate with the patient.

Other (Please provide specific details)

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Employee signature

Date

HIPAA Acknowledgement of Receipt of the Notice of Privacy Practices 2014

This form does not constitute legal advice and covers only federal, not state, law.

Acknowledgement Form Of Receipt Of Notice Of Privacy Practices