HIPAA Consent Acknowledgment Form

By signing below, I acknowledge that I have received and reviewed the Notice of Privacy Practices regarding the Health Insurance Portability and Accountability Act (HIPAA). I understand how my medical information may be used and disclosed, and I am aware of my rights regarding my health information.

SPRUILL SPEECH AND LANGUAGE SERVICES Notice of Privacy Practices (HIPAA) Acknowledgment of Receipt Effective Date: 06/01/2017 Our Commitment to Privacy At Spruill Speech and Language Services, we are committed to protecting the privacy and confidentiality of you and your child's protected health information (PHI). Federal law (HIPAA) requires us to safeguard your information and provide this Notice of Privacy Practices. How We May Use and Disclose Information • Treatment: To provide evaluations, therapy, consultations, and coordinate care. • Payment: To bill insurance companies or responsible parties. • Health Care Operations: To improve quality, conduct audits, train staff, and maintain compliance. • Required by Law: When disclosure is required by federal or state law. • Appointment Reminders: We may contact you by phone, text, email, voicemail, or mail. Uses Requiring Your Authorization We will obtain your written permission before releasing information for purposes not otherwise permitted by law, including sharing records with outside parties (when required), or using photographs/videos for educational or marketing purposes. You may revoke your authorization in writing at any time. Your Rights • Inspect and receive a copy of records • Request amendments to records • Request restrictions on certain disclosures • Request confidential communications • Receive an accounting of certain disclosures • Receive a paper copy of this notice • File a privacy complaint without fear of retaliation Our Responsibilities We maintain appropriate administrative, physical, and technical safeguards to protect your information and will notify you if a reportable breach of unsecured PHI occurs. Questions Privacy Officer: Nicole Spruill, M.ED CCC-SLP Phone: 704-464-0464 Email: info@nicolespruillacademy.com Address: 325 McGill Ave STE 533 Concord, NC 28027 Acknowledgment of Receipt I acknowledge that I have received the Spruill Speech and Language Services Notice of Privacy Practices and understand my rights under HIPAA. Patient Name: ____________________________________________ Date of Birth: ____________________________________________ Parent/Legal Guardian: ____________________________________ Relationship to Patient: ___________________________________ Signature: _________________________________________________ Date: ____________________________________________________ Office Use Only We made a good-faith effort to obtain acknowledgment of receipt. ☐ Patient/Guardian declined ☐ Emergency situation ☐ Communication barrier ☐ Other: ________________________________ Staff Signature: _________________________ Date: ____________