haelanhealth.com - Privacy Practices Acknowledgement Form

Acknowledgment of Receipt of Notice of Privacy Practices
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal health care operations such as quality assessments and physician certifications.
I have received, read and understand the Notice of Privacy Practices document containing a more complete description of the uses and disclosures of my health information. I understand that NAME OF ENTITY (“Practice”) has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below for a current copy of the Notice of Privacy Practices document.

Do we have your permission to:

	Yes	No
Leave a message on your answering machine?
Confirm appointments by leaving messages or speaking with family?
Leave pre-medication reminders (if applicable)?
Speak to household members concerning your care?

Acknowledgment of Receipt of Notice of Privacy Practices