HIPAA Privacy Receipt Acknowledgement 2017 (Form 20087)

HIPAA PRIVACY RECEIPT ACKNOWLEDGEMENT

Fred Toenges Shoes has provided me with their Notice of Privacy Practices. By signing below, I understand that Fred Toenges Shoes will not disclose any information regarding my personal health and treatment without my consent, except for such reasons as required by law, administrative proceedings, and medical billing.

I understand I have the right to review the Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices for Fred Toenges Shoes is available at the front desk.

Fred Toenges Shoes reserves the right to change the privacy practices described in the Notice of Privacy. Any changes will be available to me by calling the office, requesting a revised copy to be mailed, or asking for one at the time of my next appointment.
Printed Name of Patient*
Patients Date of Birth*

MonthDayYear
Signature of Patient/Personal Representative*

Clear
Relationship of Signer to Patient *
Date*

MonthDayYear
I authorize the following persons’ access to my protected health information (PHI):
Name

First NameLast NameSuffix
Date of Birth

MonthDayYear
Home Phone Number
Name

First NameLast NameSuffix
Date of Birth

MonthDayYear
Home Phone Number
Please enter a valid phone number.
Name

First NameLast NameSuffix
Date of Birth

MonthDayYear
Home Phone Number
Name

First NameLast NameSuffix
Date of Birth

MonthDayYear
Home Phone Number
Patients/Representatives signature:

Clear
Authorization to release PHI to the above listed individuals
Please verify that you are human*
FORM 20087
TO BE COMPLETED BY TOENGES OFFICE STAFF ONLY!
Signature and Title of person providing the “Patients Notice of Privacy”

Clear
Title
Date

MonthDayYear
Should be Empty: