HIPAA OMNIBUS RULE
PATIENT ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES AND CONSENT/LIMITED AUTHORIZATION AND RELEASE FORM 2020 (Health Insurance Portability and Accountability Act)
Today's Date
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Month
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Day
Year
Date
The undersigned acknowledges receipt of a copy of the currently effective 'Notice of Privacy Practices' for this healthcare facility, Rockaway Orthodontics. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI (protected health information) DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER DOCTORS/FACILITIES IN THE FUTURE.
Patient's Name
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First Name
Last Name
Parent/Legal Guardian Name (if patient is under 18)
First Name
Last Name
Patient OR Parent/Legal Guardian Signature (if patient is under 18)
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Clear
Relationship to Patient (if patient is under 18)
Mother
Father
Legal Guardian
PLEASE LIST ANY OTHER PARTIES THAT CAN HAVE ACCESS TO YOUR or THE PATIENT'S HEALTH, BILLING, OR APPOINTMENT INFORMATION. (This includes insurance subscribers, step-parents, grand-parents, or any caretakers who can have access to the patient's records, billing, appointments, etc.)
First Name
Last Name
Relationship to Patient
First Name
Last Name
Relationship to Patient
I authorize contact from this office to confirm my appointments and send office correspondence via: (please choose one or both)
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Email
Text message
Email
example@example.com
Cell Phone #1
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Area Code
Phone Number
Cell Phone #2 (optional)
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Area Code
Phone Number
In signing this HIPAA Patient Acknowledgement form, you acknowledge and authorize that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your acknowledgement and consent.
Submit
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