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HIPAA Privacy Acknowledgment - Free Healthcare Template | ZenBuild | ZenBuild

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HIPAA Privacy Acknowledgment

Acknowledge receipt of HIPAA privacy practices and authorize the use of protected health information.

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HIPAA Privacy Acknowledgment

Acknowledge receipt of HIPAA privacy practices and authorize the use of protected health information.

Patient Name*

Date of Birth*

Practice / Facility Name*

I acknowledge that I have received a copy of the Notice of Privacy Practices*

YesI declined to receive a copy

I authorize the practice to communicate with me via email regarding appointments and health information*

YesNo

I authorize the practice to leave voicemail messages regarding my care*

YesNo

Authorized Representative (if applicable)

Person authorized to receive health information on your behalf

Patient Signature*

I acknowledge my privacy rights under HIPAA

By signing, you agree this constitutes an electronic signature.

Date*

Template Details

CategoryHealthcare

IndustryHealthcare

Fields9

Uses0

Views2

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