HIPAA Form

Internal Medicine Associates of Lincoln Park, P.A.

Dr. Anju Budhwani
Notice of Privacy Practice Acknowledgement Form
I understand that under the Health Insurance Portability Accountability Act of 1996 (HIPAA), I have certain rights regarding my protected health information.

I have received, read, and understood the Notice of Privacy Practices, containing a description of the uses and disclosures of my health information.

I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact thsi office at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that the office will be unable to speak to anyone regarding my health information unless they are expressly named below, with no exceptions, unless otherwise dictated by HIPAA laws.

I understand that I may have to update this form from time to time, and I may request to remove or add anyone I see fit, at any time.
Patient Name:
Signature:*

Clear
Date:

MonthDayYear
Date
We often need to contact patients by phone - for example to return a phone call from you, or to confirm an appointment the day before your next visit. If you are not available, we will leave a message on your answering machine or voicemail.

If you DO NOT wish for us to leave a message on your answering machine or voicemail, CHECK
Please list the names of persons (including other physicians), as well as the relationship of those persons, with whom we are allowed to discuss the medical condition of the patient.
Emergency Contact Name:*
Emergency Contact Number:*
Should be Empty:

Notice of Privacy Practice Acknowledgement Form