springspediatricdentist.com - HIPAA & Omnibus Rule

HIPAA OMNIBUS RULE

PATIENT ACKNOWLEDGEMENT FORM FOR RECEIPT OF NOTICE OF PRIVACY PRACTICES CONSENT/LIMITED AUTHORIZATION & RELEASE FORM
You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.
Date:

MonthDayYear
Date
Patient Name:

First NameLast Name
PLEASE LIST ANY OTHER PARTIES WHO ARE ACTIVELY INVOLVED IN YOUR HEALTH CARE AND WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION: (This includes stepparents, grandparents and any care takers who can have access to this patient’s records):
Name:
Relationship:
Name:
Relationship:
I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA:
I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA:
I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO on behalf of this Healthcare Facility via:
In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.
HIPAA Notice of Privacy Practices

Please review our HIPAA Notice of Privacy Practices below. This document explains how your medical information may be used and disclosed and how you can access your information.

View the HIPAA Notice of Privacy Practices: Click here to read the HIPAA Policy
Please write name of Patient
Please sign Patient / Guardian of Patient
Legal Representative / Guardian
Relationship of Legal Representative / Guardian
OFFICE USE ONLY

As Privacy Officer, I attempted to obtain the patient’s (or representatives) signature on this Acknowledgement but did not because:

❑ It was emergency treatment.

❑ I could not communicate with the patient.

❑ The patient refused to sign.

❑ The patient was unable to sign because:

❑ Other (please describe)

Signature of Privacy Officer:
Should be Empty:

HIPAA OMNIBUS RULE