Privacy Notice Acknowledgement Form Privacy Notice Acknowledgement Form and HIPAA Policy To Our Patients: Federal law requires that we provide you with a copy of our Privacy Notice. Here is our HIPAA Privacy Notice as a PDF for you to review. The Privacy Notice explains how we may use and disclose health information about you. We ask that you sign this form for our records so that we may document your receipt of the Notice. If you have questions about the Privacy Notice, please feel free to direct these to our Privacy Officer at any time. The name and contact number of the Privacy Officer is listed on your copy of the Privacy Notice. Patient NameDate of Birth I have received and/or been offered a copy of the Privacy Notice for this organization on today’s date. Patient Name First Last Date FOR OFFICE USE ONLY If patient is unable to acknowledge receipt, staff member providing notice to complete this section The Privacy Notice was provided to Patient Name First Last FOR OFFICE USE ONLYDate The patient was unable to acknowledge receipt of the Privacy Notice for the following reason: FOR OFFICE USE ONLYPatient Name First Last FOR OFFICE USE ONLY
