Acknowledgement of Receipt of Notice of Privacy Practices

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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Notice to Patient;
We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may
use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice.
You may refuse to sign this acknowledgement, if you wish.
____________________________________________________________________________________
I acknowledge that I have received a copy of this office's Notice of Privacy Practices.
__________________________________________________________________________________________
Please print your name here
__________________________________________________________________________________________
Signature
______________________________________________________
Date
We cannot discuss your protected health information (PHI) with anyone other than yourself unless you authorize us to do
so. Please list below names(s) of the individual(s) you authorize our office to discuss
care with. Your PHI maybe disclosed to the individual(s) listed below until you notify us otherwise in writing.
_________________________________
__________________________________
_________________________________
__________________________________
FOR OFFICE USE ONLY
We have made every effort to obtain written acknowledgment of receipt of our Notice of Privacy from this patient but it
could not be obtained because:
The patient refused to sign.
Due to an emergency situation it was not possible to obtain an acknowledgement.
We weren't able to communicate with the patient.
Other (Please provide specific details)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
____________________________
___________________________
Employee signature
Date
HIPAA Acknowledgement of Receipt of the Notice of Privacy Practices 2014
This form does not constitute legal advice and covers only federal, not state, law.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Notice to Patient;
We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may
use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice.
You may refuse to sign this acknowledgement, if you wish.
____________________________________________________________________________________
I acknowledge that I have received a copy of this office's Notice of Privacy Practices.
__________________________________________________________________________________________
Please print your name here
__________________________________________________________________________________________
Signature
______________________________________________________
Date
We cannot discuss your protected health information (PHI) with anyone other than yourself unless you authorize us to do
so. Please list below names(s) of the individual(s) you authorize our office to discuss
care with. Your PHI maybe disclosed to the individual(s) listed below until you notify us otherwise in writing.
_________________________________
__________________________________
_________________________________
__________________________________
FOR OFFICE USE ONLY
We have made every effort to obtain written acknowledgment of receipt of our Notice of Privacy from this patient but it
could not be obtained because:
The patient refused to sign.
Due to an emergency situation it was not possible to obtain an acknowledgement.
We weren't able to communicate with the patient.
Other (Please provide specific details)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
____________________________
___________________________
Employee signature
Date
HIPAA Acknowledgement of Receipt of the Notice of Privacy Practices 2014
This form does not constitute legal advice and covers only federal, not state, law.

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