HIPAA PRIVACY FORM
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
This form will be provided to you upon registration. In the case of a medical emergency, this form will be
provided to you as soon as reasonably practicable after your emergency treatment is over.
Name of Patient/ Personal Representative:
You are entitled to our Notice of Privacy Practices describing how your health information can be used and
disclosed by Mid Island Audiology, PLLC and how you can obtain access to and control this information.
Our Notice of Privacy Practices will be provided to you upon registration or admission. It is also posted in our
registration areas and is available on our website at
We have additional Notices of Privacy Practices for HIV, mental health and alcohol & substance abuse
information. You can request a copy of these notices at any time.
Patient/Surrogate Name (Print): ______________________
Signature: ______________________
Date: ______________________
Time: ______________________
Patient would not acknowledge receipt of Notice of Privacy Practices. Documentation of good faith effort to
obtain acknowledgement and reason not obtained:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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Mid Island Audiology, PLLC 1065 Old Country Road, #214, Westbury, NY, 11590 5163347000