HIPAA

Patient Acknowledgement and Receipt of Notice of Privacy Practices Pursuant to HIPPA and Consent for Use of Health Information
Name
Date
Date Format: MM slash DD slash YYYY
The undersigned does hereby acknowledge that he or she has received a copy of this office's Notice of Privacy Practices Pursuant to HIPPA and has been advised that a full copy of this office's HIPPA Compliance Manual is available upon request.

The undersigned does hereby consent to the use of his or her health information in a manner consistent with the Notice of Privacy Pursuant to HIPPA, the HIPPA compliance Manual, State and Federal Law.
Authorized to release medical information by
List your name
Authorized on this date
Date Format: MM slash DD slash YYYY
Authorized to release medical information on this patient behalf
First Last
Phone number
Email
If patient is a minor or under guardianship order as defined by state law:
Signature of Parent/Guardian