FOR PATIENTS

HIPPA Form

 

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HIPAA OMNIBUS RULE
PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM

*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.

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:



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):
Name:
Relationship:
Name:
Relationship:

I authorize contact from this office to confirm my appointments, treatment & billing information via:
Cell Phone Confirmation
Email Confirmation
I authorize information about my health be conveyed via:
Cell 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:
Phone Message Text Message
 
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.

Signature (Please Initial):   


For 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