Hipaa Omnibus Rule - Patient Acknowledgement Of Receipt Of Notice Of Privacy Practices And Consent/limited Authorization And Release Form

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HIPAA OMNIBUS RULE
PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
AND CONSENT/LIMITED AUTHORIZATION AND RELEASE FORM
You may refuse to sign this acknowledgement and authorization.
In refusing we will not be able to process your insurance claims so you will be responsible for payment in full of any and all visits.
Date:________________________
The undersigned acknowledges receipt of a copy of the currently effective Notice Of Privacy Practices for this
healthcare facility.
MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE IF I REQUEST TESTING
OR TREATMENT RESULTS BE SENT TO ANOTHER DOCTOR/FACILITY IN THE FUTURE.
_______________________________________
____________________________________
Please PRINT your name
Please SIGN your name
______________________________________
____________________________________
Legal Representative
Description of Authority
HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM RECEPTION AREA:
_____ FIRST NAME
_____ PROPER SURNAME
_____OTHER _________________________
PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
(This includes spouses and any care takers who can have access to this patient’s records:
NAME_________________________________
RELATIONSHIP_____________________
NAME_________________________________
RELATIONSHIP_____________________
I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS OR
TREATMENT AND BILLING INFORMATION VIA:
_____ CELL PHONE
_____ HOME PHONE CONFIRMATION ____ WORK PHONE CONFIRMATION
#___________________
____________________________
____________________________
I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA:
_____ CELL PHONE
_____ HOME PHONE CONFIRMATION ____ WORK PHONE CONFIRMATION
I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING
EFFORTS OR NEW HEALTH INFO ON BEHALF OF THIS HEALTHCARE FACILITY VIA:
_____ CELL PHONE
_____ HOME PHONE CONFIRMATION ____ WORK PHONE CONFIRMATION
In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, this office may recommend products or
services to promote your improved health. This office may or may not receive third party remuneration from these affiliated
companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.
____________________________________________________________________________________________________________
OFFICE USE ONLY: As Privacy Officer, I attempted to obtain the patient’s or representatives) signature on this Acknowledgement
but did not because:
_____It was emergency Treatment _____ I could not communicate with the patient _____ The patient refused to sign
_____The patient was unable to sign because/other reason
____________________________________________________Print and Signature of Privacy Officer

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