Patient Acknowledgement of Receipt of Notice of Privacy Practices and Consent/Limited Authorization Release Form

HIPAA Omnibus Rule

You may refuse to sign this acknowledgement & authorization. In refusing, we may not be allowed to process your insurance claims.

Date

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Please print name of Patient

Please sign for Patient/Guardian of Patient

Legal Representative/Guardian

Relationship of Legal Representative/Guardian

Your comments regarding Acknowledgements or Consents:

How do you want to be addressed when summoned from the reception area:

First Name Only

Proper Sir Name

Other

If other, please define:

Please list any other parties who can have access to your health information. (This includes step parents, grandparents, and any care takers who can have access to this patient's records.)

Add new row

I authorize contact from this office to confirm my appointments, treatment, and billing information via:

Cell Phone Confirmation

Home Phone Confirmation

Work Phone Confirmation

Text Message to my Cell Phone

Email Confirmation

Any of the Above

I authorize information about my health to be conveyed via:

Cell Phone Confirmation

Home Phone Confirmation

Work Phone Confirmation

Text Message to my Cell Phone

Email Confirmation

Any of the Above

I approve being contacted about special services, events, fund raising efforts, or new health info on behalf of this Healthcare Facility via:

Phone Message

Text Message

Any of the Above

None of the Above (opt out)

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that 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

Because:

Other:

Your information will be encrypted.