HIPAA Privacy Acknowledgement

Fairmount Speech and Swallowing Therapy

Philadelphia, PA

contact@fairmountspeech.com

(215) 645-2699
HIPAA Privacy Acknowledgement
Fairmount Speech and Swallowing Therapy is required by law to keep your health information and records safe including:
- Notes from your doctor, teacher or other healthcare provider
- Medical history
- Test results
- Treatment notes
- Insurance information
We are required by law to give you a copy of our privacy notice. This notice tells you how your health information may be used and shared.
I acknowledge that I have received a copy of Fairmount Speech and Swallowing Therapy HIPAA Notice of Privacy Practices that fully explains the uses and disclosures they will make with respect to my individually identifiable health information. I have had the opportunity to read the notice and to have any questions regarding the notice answered to my satisfaction. I understand Fairmount Speech and Swallowing Therapy cannot disclose my health information other than as specified in the notice. I understand that Fairmount Speech and Swallowing Therapy reserves the right to change the notice and the practices detailed therein if it sends a copy of the revised notice to the address I have provided.
Print Name of Client
Date

Month Day Year
Date
Signature of Client or Legal Representative

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Relationship to Client
Please Note: It is your right to refuse to sign this Acknowledgement.

HIPAA Privacy Notice Acknowledgement
I tried to obtain written Acknowledgement of our Privacy Notice by the caregiver/legal representative noted above. It could not be obtained for the following reason(s):

-An emergency prevented us from obtaining acknowlegement

-The individual was unwilling to sign

-A communication barrier prevented us from obtaining acknowledgement.
Other:
Staff Member Signature

Clear
Date

Month Day Year
Date
Should be Empty: