HIPAA Acknowledgement HIPAA Acknowledgement ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE AND CONSENT TO USE AND DISCLOSURE FOR TREATMENT, PAYMENT AND OPERATIONS PURPOSES By signing below, I hereby acknowledge that I have been provided the opportunity to obtain a copy of this office’s Notice of Privacy Practices and have therefore been advised of how my protected health information may be used and disclosed by the office and how I may obtain access to and control this information. It is posted in the waiting room and available for copy on request. In addition, by signing below, I hereby consent to the use and disclosure of my health information for treatment purposes, payment activities and healthcare operations of the office. I understand that I may refuse to sign this authorization. Treatment, payment, enrollment in a health plan or eligibility for benefits will not be conditioned on signing an authorization if to do so would be prohibited by federal and state law. I may revoke authorization in writing at any time. If I do, it will not affect any previous actions already taken in reliance upon my authorization. I may revoke this authorization by writing a letter and mailing it by certified mail, return receipt requested to the Privacy Officer at the health care provider listed above. Once health information is disclosed pursuant to this authorization, it may be re-disclosed and may no longer be protected by privacy laws. Printed Name of Patient or Legal Representative * First * Last Email * Signature Clear Electronic Disclosure, Electronic Signature and Electronic Statements Agreement Please read this Electronic Records Disclosure and Agreement carefully: By checking the boxes on the website for patient forms, AND, by typing your name in the e-sign box here, you consent to the electronic delivery of the disclosures, information you provided, terms and conditions and any other documents to be included in your electronic and paper copy records. You also agree that we do not need to provide you with additional paper (non-electronic) copies of the disclosures, agreements, change notices, terms and conditions and any other documents, unless specifically requested. Once you consent to the disclosures and inclusion of your HIPAA protected information to be included in your records, you may request paper copies, which may result in a small copying fee. Date Captcha If you are human, leave this field blank. Submit
