Acknowledgement of Privacy Practices

My signature confirms that i have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA).  I understand that this information can and will be used to:

  • Proved and coordinate my treatment among a number of healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers for my health care services.
  • Conduct normal health care operations such as quality assessment and improvement activities.

I have been informed of my healthcare provider’s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information.  I have been given the right to review and receive a copy od such Notice of Privacy Practices.  I understand that my healthcare provider has the right to change the Notice of Privacy Practices and that i may contact this office at the addresses above to obtain a current copy of the Notice of Privacy Practices.  Importantly the updated 9-23-13 version of the NOPP reflecting the OMNIBUS rule.

I understand that i may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

* Required information

Patient's Name*:

Your Name*:

Last Name*:


Relationship to Patient*:

Names of family dependent also covered by this acknowledgement:

Additional Disclosure Authority: (concluded with discussion RE: patient etc.)

Patient/Legal Guardian's Signature*,
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