HIPAA OMNIBUS RULE
Patient Acknowledgment of Receipt of Notice of Privacy Practice and Consent/Limited Authorization & Release Form
You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.
Patient Name
*
First Name
Middle Name
Last Name
How do you want to be addressed when summoned from the reception area:
First Name Only
Proper Sir Name
Other
Cell Phone
*
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Email
*
example@example.com
I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA:
*
Cell Phone Confirmation
Text Message to My Cell Phone
Home Phone Confirmation
Email Confirmation/Rewards Program (BELLY)
Work Phone Confirmation
Any of the Above
Other
I AUTHORIZE INFORMATION ABOUT MY HEALTH TO BE CONVEYED VIA:
*
Cell Phone Confirmation
Text Message to my Cell Phone
Home Phone Confirmation
Email Confirmation/Rewards Program (BELLY)
Work Phone Confirmation
Any of the Above
Other
I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO on behalf of this Healthcare Facility via:
*
Phone Message
Text Message
Email
Any of the Above
None of the Above (opt out)
PLEASE LIST ANY OTHER PARTIES (this includes step parents, grandparents and any care takers who can have access to this patient's records) WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
Name
First Name
Last Name
Relationship:
Name
First Name
Last Name
Relationship
The undersigned acknowledges the receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITIES IN THE FUTURE.
Please Print Your Name
*
Date
*
-
Month
-
Day
Year
Date
Signature
Clear
Legal Representative
Description of Authority
Your Comments Regarding Acknowledgement or Consents:
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 knowledge and consent.
Submit
Office Use Only
As Privacy Officer, I attempted to obtain the patient's (or representatives) signature on this Acknowledgement but did not because:
It was emergency treatment
I could not communicate with the patient
The patient refused to sign
The patient was unable to sign
Other
If applicable, please specify details on why the patient did not sign
Name of Privacy Officer
Signature of Privacy Officer
Clear
Should be Empty: