HIPAA Privacy Policy Acknowledgment Form

Motion Foot and Ankle
A Division of Modern Medical Group
5139 Mattis Road, STE 102
St. Louis, MO 63128
314-396-9517
support@mfa-stl.com

HIPAA Privacy Policy Acknowledgment

We are required by law to provide you with our Notice of Privacy Practices, which explains how your Protected Health Information (PHI) may be used and disclosed, as well as your rights regarding your health information. This form serves as an acknowledgment that you have been provided with a copy of this notice.
Please review the following and sign below to confirm your acknowledgment:

Patient Acknowledgment

I, the undersigned, acknowledge that I have been provided with a copy of Modern Medical Group Notice of Privacy Practices. I understand that this notice explains:

• How Modern Medical Group may use and disclose my health information for purposes of treatment, payment, and healthcare operations.
• My rights to access, inspect, and obtain a copy of my health records.
• My right to request an amendment to my health records if I believe there is an error.
• My right to request restrictions on the use and disclosure of my health information.
• My right to request confidential communications regarding my health information.
• My right to file a complaint if I believe my privacy rights have been violated.

I understand that I may contact the practice’s Privacy Officer at Modern Medical Group for more information, or to file a complaint if I have any concerns about the privacy of my health information.
blanksblank

For Office Use Only:

If the patient or patient’s representative did not sign this acknowledgment form, please provide the reason why acknowledgment could not be obtained:

• ☐ Patient refused to sign
• ☐ Communication barriers prohibited obtaining acknowledgment
• ☐ Emergency situation
• ☐ Other (please specify): ___________________________________

Staff Member Name: ________________________________________________
Date: ________________________________________________________________
This form should be maintained in the patient’s medical record for compliance purposes.
Effective Date: 06/01/2024
This document ensures compliance with the Health Insurance Portability and Accountability Act (HIPAA) and protects the privacy of patient information.