• 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.

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  • 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:
  • 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.
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  • 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.
  • Office Use Only

    As Privacy Officer, I attempted to obtain the patient's (or representatives) signature on this Acknowledgement but did not because:

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