Harmony Ortho Hipaa form

Privacy Notice Acknowledgment

To Our Patients,

Federal law requires that we provide you with a copy of our Privacy Notice.

The Privacy Notice explains how we may use and disclose health information about you. We ask that you sign this form for our records so that we may document your receipt of Notice.

If you have questions about the Privacy Notice, please feel free to direct these to our Privacy Officer at any time. The name and contact or the Privacy Officer is listed on your copy of the Privacy Notice.
Patient Name
Date of Birth

MonthDayYear
Date
Patient or Guardian to complete this section:

I have received a copy of the Privacy Notice for this organization for today's date.
Signed

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Date

MonthDayYear
Date
If patient is unable to acknowledge receipt, staff member providing notice to complete this section:

The Privacy Notice was provided to:
Patient Name
On
The patient was unable to acknowledge receipt of the Privacy Notice for the following reason
Signed

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Should be Empty:

Privacy Notice Acknowledgment