HIPAA Acknowledgement of Receipt, English

"*" indicates required fields

The Health Insurance Portability and Accountability Act of 1996 requires that health care providers give patients a copy of the office Notice of Privacy Practices. It also requires the business to make a good faith effort to obtain an acknowledgement of receipt of the same. It is your right to refuse to sign.

Patient Name*

Date of Birth*

By my signature below I acknowledge that I have been provided a copy of the Notice of Privacy Practices for the above named pediatric medical practice and I have read or had the opportunity to read (if I so chose) and understand the content of the notice

Optional

In addition, I hereby give my permission for the following people, whom I have designated below, to have complete access to the patient’s medical records named within. This includes permission for the staff of the practice to discuss and provide the patient’s account information.

Name

Relationship to the patient

Phone number

Name

Relationship to the patient

Phone number

Patient/Parent or Legal Guardian name*

First Last

Today's Date*

Signature*

HIPAA Acknowledgement of Receipt, English

Optional

Make An Appointment

Phone Calls

Emergencies

Appointments