Hipaa Form - Texas Acupuncture Clinic printable pdf download

Hipaa Form - Texas Acupuncture Clinic

TEXAS ACUPUNCTURE CLINIC

HIPAA Acknowledgement and Appointment Reminders Form

I acknowledge that I have been provided access to the Texas Acupuncture Clinic (TAC) “Notice

of Privacy Practices”. I understand that I have the right to review TAC’s “Notice of Privacy

Practices” prior to signing this document.

I understand that TAC staff members may need to contact me with appointment reminders or

information related to my treatments. If this contact is to be made by phone, and I am not at

home, a message will be left on my answering machine or with anyone who answers the phone.

Information stripped of any personal identifiers may also be used for research and educational

purposes by individual practitioners or TAC. By signing this form, I am giving Texas

Acupuncture Clinic authorization to contact me with these reminders and to utilize my

information for research and educational purposes.

__________________________________________

______________________________

Patient Name (print)

Date

___________________________________________

______________________________

Patient Signature

TAC Privacy Rep/Date

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Authorization for Release of Health Information (Optional)

I, ___________________________________________________, hereby authorize the Texas

Acupuncture Clinic the use or disclosure of my individually identifiable health information to

the party(s) described below. I understand this authorization is voluntary. I understand if the

party(s) authorized to receive my information is/are not a health plan or health care provider,

the released information may no longer be protected by federal privacy regulations.

Persons/Organizations authorized to receive information: (please print)

____________________________________

Patient’s Signature

Date

Hipaa Form - Texas Acupuncture Clinic