HIPAA Acknowledgment Form - PatientNotes.ai

Practice Name: _______________________________________________

Address: _______________________________________________

Phone: _____________________ Fax: _____________________

PURPOSE OF THIS FORM

This form acknowledges that you have received a copy of our Notice of Privacy Practices, which describes how medical information about you may be used and disclosed, and how you can get access to this information.

YOUR RIGHTS UNDER HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) provides you with certain rights regarding your protected health information (PHI). These rights include:

Right to Access: You may request to inspect and obtain a copy of your medical records.
Right to Amend: You may request amendments to your health information if you believe it is incorrect or incomplete.
Right to Accounting: You may request a list of disclosures we have made of your health information.
Right to Restrict: You may request restrictions on certain uses and disclosures of your health information.
Right to Confidential Communications: You may request that we communicate with you in a specific way or at a specific location.
Right to a Paper Copy: You may request a paper copy of our Notice of Privacy Practices at any time.

HOW WE MAY USE AND DISCLOSE YOUR INFORMATION

We may use and disclose your protected health information for the following purposes:

Treatment: To provide, coordinate, or manage your healthcare and related services.
Payment: To bill and collect payment for healthcare services provided to you.
Healthcare Operations: For quality assessment, training, licensing, and other administrative purposes.
As Required by Law: When required by federal, state, or local law.
Public Health: For public health activities such as preventing disease or reporting adverse reactions.
Health and Safety: To prevent or lessen a serious threat to health or safety.

Other uses and disclosures not described in this notice will be made only with your written authorization.

Patient Name (Printed)

Date of Birth

Medical Record Number

PATIENT ACKNOWLEDGMENT

I acknowledge that I have received a copy of this practice's Notice of Privacy Practices, which describes how my health information may be used and disclosed.

I understand that I have the right to review the Notice of Privacy Practices before signing this acknowledgment.

I understand that this practice reserves the right to change its privacy practices and that I may obtain a revised notice upon request.

Patient Signature (or Authorized Representative)

Date

Printed Name of Authorized Representative (if applicable)

Relationship to Patient

FOR OFFICE USE ONLY

If the patient refuses to sign or is unable to sign this acknowledgment, document the reason below:

Reason

Staff Member Name

Date

ACKNOWLEDGMENT OF RECEIPT

Notice of Privacy Practices (HIPAA)

PATIENT ACKNOWLEDGMENT

FOR OFFICE USE ONLY