HIPAA Privacy Notice Acknowledgment Form

Patient Full Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Preferred Communication Method

Other

Are you the patient or a personal representative?

If you are a personal representative, please specify your relationship to the patient

Please acknowledge that you have received and understood our privacy notice

Would you like a copy of the privacy notice?

Questions or Comments

Signature

Date Signed

Date