Healthcare Privacy Practices Acknowledgment

HEALTHCARE PRIVACY PRACTICES ACKNOWLEDGMENT

Patient Information

Patient Name:    Date of Birth:    Gender:

Insurance Information (if applicable)

Acknowledgment of Notice of Privacy Practices

I acknowledge that I have been given the opportunity to review the Notice of Privacy Practices describing how my protected health information (PHI) may be used and disclosed by this provider, and how I may access this information. I understand that the Notice contains a full description of my rights and the provider's duties regarding my PHI.

Please indicate receipt status:    I received a copy of the Notice of Privacy Practices.    I was offered but declined a copy.

Interpreter present at time of notice (if applicable):

Permitted Uses and Disclosures

I understand and consent that my PHI may be used and disclosed by the provider for purposes of treatment, payment and health care operations, as described in the Notice. Uses beyond treatment, payment and health care operations will only be made with my written authorization, except as otherwise permitted or required by law.

The provider may disclose PHI without my authorization when required by law, for public health activities, to report abuse, neglect or domestic violence, for judicial and administrative proceedings, for law enforcement purposes, and for certain specialized government functions as permitted by law.

Patient Rights Summary

I understand that I have the right to: request restrictions on certain uses and disclosures of my PHI; request confidential communications; inspect and obtain a copy of my PHI; request amendment of my PHI; and receive an accounting of disclosures of my PHI as provided by law. I may exercise these rights by submitting a written request to the provider's designated privacy officer or administrative office.

Communications and Message Preferences

Please indicate how we may contact you regarding appointments, test results, or billing. I authorize the provider to contact me as follows (check all that apply):

Phone call to primary number    SMS / text message    Email (for non-secure communications)    Postal mail

If you do not want messages left on voicemail or with another person, check here: Do not leave voicemail messages or detailed information with household members.

Revocation and Limitation

I understand that I may revoke or limit this acknowledgment or any permission granted herein at any time, except to the extent that the provider has already taken action in reliance on this acknowledgment. Revocation or requests for limitation must be submitted in writing to the provider's administrative office or privacy officer.

Additional Requests / Restrictions

By signing below, I acknowledge that I have read and understand this Healthcare Privacy Practices Acknowledgment and that I have been given the opportunity to receive and review the Notice of Privacy Practices. My signature below indicates my receipt, or documented offer, of the Notice and my preferences for communications as indicated above. I understand that this acknowledgment is not an authorization for release of records beyond the uses described in the Notice, and separate written authorization is required for most disclosures not otherwise permitted by law.

Authorization Expiration

This acknowledgment and any consents indicated herein remain in effect until revoked in writing, or until: (enter an expiration date if desired).

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