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Free HIPAA Privacy Acknowledgement Form Template

Free HIPAA Privacy Acknowledgement Form

Name: Free HIPAA Privacy Acknowledgement Form Template
Brand: Template.net
Availability: InStock

HIPAA Privacy Acknowledgement Form

Please sign to acknowledge that you have received the Notice of Privacy Practices.

Date

Name

Phone Number

Email

Acknowledgment of Receipt

I, the undersigned, acknowledge that I have received a copy of the company's Notice of Privacy Practices.

The Notice of Privacy Practices outlines:

How my Protected Health Information (PHI) may be used or disclosed.
My rights regarding my PHI under HIPAA.
The procedures to access, amend, or restrict the use of my PHI.

I understand that if I have any questions regarding the Notice of Privacy Practices, I may contact the company at the information provided.

Consent for Communications

I authorize the company to contact me regarding my healthcare using:

Email
Phone

I understand that communications via email or text may not be encrypted and could pose a privacy risk.

Name:

Date:

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Ensure patients are informed about their privacy rights using the HIPAA Privacy Acknowledgement Form Template from Template.net. Fully editable and customizable, this template allows healthcare providers to document that patients have received and understood their HIPAA privacy rights. Personalize it using our AI Editor Tool for clarity and professionalism while meeting regulatory standards.