HIPAA Privacy Acknowledgment

HIPAA Privacy Acknowledgment — Form Fields

This healthcare template includes 9 fields. Acknowledge receipt of HIPAA privacy practices and authorize the use of protected health information. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Practice / Facility Name (text, required)
• I acknowledge that I have received a copy of the Notice of Privacy Practices (multiple choice, required) — options: Yes, I declined to receive a copy
• I authorize the practice to communicate with me via email regarding appointments and health information (multiple choice, required) — options: Yes, No
• I authorize the practice to leave voicemail messages regarding my care (multiple choice, required) — options: Yes, No
• Authorized Representative (if applicable) (text, optional) — Person authorized to receive health information on your behalf
• Patient Signature (signature, required) — I acknowledge my privacy rights under HIPAA
• Date (text, required)