HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

You have the right to read our Notice of of Privacy Practices before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

I have had an opportunity to read and consider the conents of this Consent form and your Notice of Privacy Practices. I understand that by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

Patient First Name:

Last Name:

Patient/Parent/Guardian E-Signature:

Date:

Relationship to Patient:

Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign

Communication barriers prohibited obtaining the acknowledgement

An emergency prevented us from obtaining the acknowledgement

Other (Please Specify)

Other Explanation: