Free HIPAA Privacy Acknowledgement Form Template

HIPAA Privacy Acknowledgement Form

Please sign to acknowledge that you have received the Notice of Privacy Practices.

Date

    Name

      Phone Number

        Email

          Acknowledgment of Receipt

          I, the undersigned, acknowledge that I have received a copy of the company's Notice of Privacy Practices.

          The Notice of Privacy Practices outlines:

          1. How my Protected Health Information (PHI) may be used or disclosed.

          2. My rights regarding my PHI under HIPAA.

          3. The procedures to access, amend, or restrict the use of my PHI.

          I understand that if I have any questions regarding the Notice of Privacy Practices, I may contact the company at the information provided.

          Consent for Communications

          I authorize the company to contact me regarding my healthcare using:

            • Email

            • Phone

            I understand that communications via email or text may not be encrypted and could pose a privacy risk.

            Name:

            Date:

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