HIPPA Acknowledgment Form

HIPPA Acknowledgment Form

Patient HIPPA Acknowledgment & Designation Disclosure Form
I. Acknowledgement of Practices's Notice of Privacy Practices:

By subscribing my name below, I acknowledge that Envision Psychiatry, has provided a copy of the Notice of Privacy (NPP) and that I have read (or had the opportunity to read if I so chose) and understand my rights and ask questions regarding my rights and receive answers to my satisfaction, and agree to its terms.
Name Of Patient: *

First NameLast Name
Signature*

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Today's Date: *

MonthDayYear
Date
II. Designation of Certain Relatives, Close Friends and other Caregivers as my Personal Representative:

I agree that the practice may disclose certain of my health information to a Personal Representative of my choosing, since such person is involved with my health care of payment relating to my health care. In the case, the Physician Practice will disclose only information that is directly relevant to the person's involvement with my health care of payment relating to my health care.
How many individuals do you want to release information to?*

123
Name*

First NameLast Name
Date Of Birth: *

MonthDayYear
Date
Phone Number:*
Please enter a valid phone number.
Name*

First NameLast Name
Date Of Birth: *

MonthDayYear
Date
Phone Number:*
Please enter a valid phone number.
Name*

First NameLast Name
Date Of Birth: *

MonthDayYear
Date
Phone Number:*
Please enter a valid phone number.
I (Parent/Guardian print)* acting on behalf of my minor son/daughter (Name Of Patient)* ,
as legal Personal Representative in all matters. If representative is a court appointed legal gaurdian, a copy of court documents must be provided and kept in medical records.

III. Request to Recieve Confidential Communication by Alternative Means:

I understand that as part of my health care and treatment that Envision Psychiatry may need to reach me by phone. As provided by Privacy Rule Section 164.522(b).

Option One:

( ) I DO hereby authorize and request that Envision Psychiatry, make all communications to me by the alternative means that I have listed below regarding instructions/procedures, clinical test results, billing and/or appointment needs, etc.
Home/Cell Telephone Number: *
Please enter a valid phone number.
Email: *
example@example.com
Which method of communication, would you like us to leave a detailed message?*

PhoneEmail
Name Of Patient: *

First NameLast Name
Patient Signature: *

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Today's Date: *

MonthDayYear
Date
Option Two:

( ) I DO NOT authorize Envision Psychiatry to contact me, to leave a message on my home or cell phone regarding communication of my health care/treatemt such as instructions for procedures, clinical test results, billing and/or appointment needs, etc.

I understand that by selecting this option it may result in delayed communication of pertinent treatment information such as medication changes, appointment confirmation, billing communications or clinical call backs. I understand that I will be responsible to make appointments to obtain this information.
Which option do you want to choose?*

12
Patient Signature of Acknowledgment of Envision Psychiatry HIPPA Authorization Form: *

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If you have any questions regarding this notive or any of our office policies, please contact the Practice Administrator at 516-988-0974. Thank you.
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