Notice Of Privacy Practices Form printable pdf download

PATIENT ACKNOWLEDGEMENT

Patient Name _____________________________________________ Date of Birth ____________________

I have received this practice’s Notice of Privacy Practices written in plain language. The Notice provides in detail

the uses and disclosures of my protected health information that may be made by this practice, my individual

rights and the practice’s legal duties with respect to my protected health information. The Notice includes:

• A statement that this practice is required by law to maintain the privacy of protected health information.

• A statement that this practice is required to abide by the terms of the notice currently in eﬀect.

• Types of uses and disclosures that this practice is permitted to make for each of the following purposes:

treatment, payment, and health care operations.

• A description of each of the other purposes for which this practice is permitted or required to use or disclose

protected health information without my written consent or authorization.

• A description of uses and disclosures that are prohibited or materially limited by law.

• A description of other uses and disclosures that will be made only with my written authorization and that I may

revoke such authorization.

• My individual rights with respect to protected health information and a brief description of how I may exercise

these rights in relation to:

- The right to complain to this practice and the Secretary of HHS if I believe my privacy rights have been

violated, and that no retaliatory actions will be used against me in the event of such a complaint.

- The right to request restrictions on certain uses and disclosures of my protected health information, and

that this practice is not required to agree to a requested restriction.

- The right to receive con dential communications of protected health information.

- The right to inspect and copy protected health information.

- The right to receive an accounting of disclosures or protected health information.

- The right to obtain a copy of the Notice of Privacy Practices from this practice upon request.

This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions

e ective for all protected health information that it maintains. I understand that I can obtain this practice’s Notice of

Privacy Practices upon request.

Signature _____________________________________________

Date __________________________

Relationship to patient (if signed by a personal representative of patient) ____________________________

301 Fellowship Road, Mt. Laurel, NJ 08054 | 856-222-1100 | 856-222-4180 fax

Notice Of Privacy Practices Form