HIPAA OMNIBUS RULE
PATIENT ACKNOWLEDGEMENT FORM FOR RECEIPT OF NOTICE OF PRIVACY PRACTICES CONSENT/LIMITED AUTHORIZATION & RELEASE FORM
You may refuse to sign this acknowledgement & authorization. ln refusing we may not be allowed to process your insurance claims.
Date: Patient Name:
HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM RECEPTION AREA:
First Name Only Proper Surname Other
PLEASE LIST ANY OTHER PARTIES WHO ARE ACTIVELY INVOLVED IN YOUR HEALTH CARE AND WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION: (This includes step parents, grandparents and any care takers who can have access to this patient's records):
Name:	Relationship:
Name:	Relationship:
I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA:
Cell Phone Confirmation	Email Confirmation
Text Message to my Cell Phone	Work Phone Confirmation
Home Phone Confirmation	Any of the Above
I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA:
Cell Phone Confirmation	Email Confirmation
Text Message to my Cell Phone	Work Phone Confirmation
Home Phone Confirmation	Any of the Above
I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO on behalf of this Healthcare Facility via:
Phone Message	Any of the Above
Text Message	None of the Above (opt out)
Email
ln 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.
The undersigned acknowledges 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 name of Patient	Please sign Patient / Guardian of Patient
Legal Representative / Guardian	Relationship of Legal Representative / Guardian
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 because Other (please describe)
Signature of Privacy Officer