Privacy Notice Form

Privacy Notice
Patient Name*

First NameLast Name
Email*
example@example.com
ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE

This Privacy Notice is being provided to you as a requirement of a federal law, the Health Insurance Portability and Accountability Act (HIPAA)
I acknowledge that I have received the attached Privacy Notice*

Draw SignatureUpload Signature
I acknowledge that I have received the attached Privacy Notice*

Clear
Patient or Personal Representative Signature
I acknowledge that I have received the attached Privacy Notice*

Patient or Personal Representative Signature
Cancelof
If Personal Representative’s signature appears above, please describe Personal Representative’s relationship to the patient:*
Type N/A if not applicable
Date*

DayMonthYear
Please answer the following questions to help us protect your privacy:
1) May we leave a detailed message on your answering machine? *

YesNo
Phone Number*
Please enter a valid phone number.
Contact Number*
2) May we leave a message at your place of employment? *

YesNo
Phone Number*
Please enter a valid phone number.
Contact Number*
Please let us know how you wish to be notified by our office.*
3) May we release information to anyone other than you? (i.e. spouse, child, friend, etc)*

YesNo
Name*

NameRelationship
Name

NameRelationship
WE WILL NOT RELEASE INFORMATION TO ANYONE NOT LISTED ABOVE
Should be Empty:

Privacy Notice