Legal HIPAA Acknowledgment Form

LEGAL HIPAA ACKNOWLEDGMENT FORM

This HIPAA Acknowledgment and Consent (the Acknowledgment) is made by and between Patient Name: (Patient) and Covered Entity Name: (Covered Entity). Effective Date: .

RECITALS

WHEREAS, Covered Entity maintains and may use or disclose certain protected health information of Patient as defined by the Health Insurance Portability and Accountability Act and its implementing regulations (HIPAA); and

WHEREAS, Covered Entity has prepared a Notice of Privacy Practices describing the uses and disclosures of protected health information and Patient's rights with respect to such information; and

WHEREAS, Patient acknowledges receipt of the Notice of Privacy Practices and provides certain consents and authorizations as set forth herein to permit Covered Entity to use and disclose Patient's protected health information consistent with HIPAA.

NOW, THEREFORE, in consideration of the mutual covenants and conditions set forth below, the parties agree as follows:

1. DEFINITIONS

For purposes of this Acknowledgment, "Protected Health Information" (PHI) has the meaning given in HIPAA and includes information created or received by Covered Entity that relates to Patient's past, present or future physical or mental health condition, provision of health care, or payment for health care.

2. ACKNOWLEDGMENT OF RECEIPT

Patient acknowledges that Covered Entity has made the Notice of Privacy Practices available and that Patient has been afforded an opportunity to review the Notice. Patient indicates:

I acknowledge I received the Notice of Privacy Practices and understand my rights under HIPAA.

If acknowledgment not signed:

3. PERMITTED USES AND DISCLOSURES

Patient consents to the use and disclosure of PHI by Covered Entity for purposes of treatment, payment, and healthcare operations as required or permitted by HIPAA. Patient further authorizes Covered Entity to:

Use and disclose PHI for treatment purposes.

Use and disclose PHI for payment activities.

Use and disclose PHI for healthcare operations.

4. ADDITIONAL AUTHORIZATIONS

Patient may authorize additional uses or disclosures by checking the boxes below and providing any necessary designation of recipients.

Authorize Covered Entity to contact me with appointment reminders, treatment instructions, or health-related information at the contact information below.

I specifically authorize use or disclosure of PHI for marketing purposes or for sale of PHI as permitted by law (if applicable, additional written authorization will be required).

5. RESTRICTIONS AND CONFIDENTIAL COMMUNICATIONS

Patient has the right to request restrictions on uses and disclosures of PHI and to request confidential communications. Requests should describe the requested restriction or method of contact and the reasons for the request. Covered Entity will review and respond in accordance with applicable law.

6. REVOCATION

Patient may revoke any authorization provided herein at any time by submitting a written revocation to Covered Entity. Revocation will not affect disclosures already made in reliance on this Acknowledgment prior to receipt of the revocation. Revocation must be signed and dated by Patient and should identify the specific authorization to be revoked.

7. MINIMUM NECESSARY

Covered Entity will make reasonable efforts to limit the PHI disclosed or used to the minimum necessary to accomplish the intended purpose, in accordance with HIPAA and Covered Entity policies.

8. BREACH NOTIFICATION AND SAFEGUARDS

Covered Entity maintains administrative, technical and physical safeguards to protect PHI. In the event of an unauthorized use or disclosure constituting a breach under HIPAA, Covered Entity will provide notification as required by law.

9. REMEDIES AND LIMITATION OF LIABILITY

Patient may complain to Covered Entity and to the appropriate government agencies if Patient believes Patient's privacy rights have been violated. Covered Entity will not retaliate against Patient for filing a complaint. To the extent permitted by law, Covered Entity's liability for unauthorized disclosures shall be limited to the remedies provided by applicable statutes and regulations.

10. NOTICES

11. AMENDMENTS, WAIVER, AND COUNTERPARTS

This Acknowledgment may be amended only by a written instrument executed by both parties. Waiver of any provision will not be effective unless in writing. This Acknowledgment may be executed in counterparts, each of which shall be deemed an original.

12. GOVERNING LAW, ENTIRE AGREEMENT, SEVERABILITY

This Acknowledgment shall be governed by the laws applicable to the Covered Entity's principal place of business without regard to conflict of law provisions. This Acknowledgment constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior communications and understandings. If any provision is held invalid, the remainder of the Acknowledgment shall continue in full force and effect.

CERTIFICATION

By signing below, Patient certifies that Patient has read and understands this Acknowledgment, that Patient's questions (if any) regarding the Notice of Privacy Practices have been answered, and that Patient consents to the uses and disclosures of PHI described herein except as otherwise indicated in writing.

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