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.

  • I have received and/or been offered a copy of the Privacy Notice for this organization on today’s 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

  • FOR OFFICE USE ONLY
  • The patient was unable to acknowledge receipt of the Privacy Notice for the following reason:

  • FOR OFFICE USE ONLY
  • FOR OFFICE USE ONLY
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