Acknowledgment of Receipt of Notice of Privacy
Practices and HIPAA Communication Consent Form
This consent form allows the Organization to use and
disclose information about me protected under the
Health Insurance Portability and Accountability Act of
1996. This information may be used or disclosed to
carry out treatment, payment or health care
The Organization has provided me with a Notice of
Privacy Practices, which more completely describes
such uses and disclosures. It provided this notice
prior to my signing this form in accordance with my
right to review its practices before signing consent.
I understand that the terms of the Notice of Privacy
Practices may change and that | may obtain revised
notices by contacting the Privacy Officer at the
I understand that at any time | have the right to revoke
this consent provided that | do so in writing, but that
the Organization services may still use information to
complete any actions that it began prior to my revoking
consent and which rely on my protected health
information. I understand that the Organization may
refuse service if I revoke this consent.
I understand that I have the right to request - now and
in the future - how protected health information is used
or disclosed to carry out treatment, payment and health
care operations, and must be provided by me in writing.
| understand that while the Organization is not required
to agree to my requested restrictions, if it does agree,
it is bound by that agreement.
By my signature below, I affirm the above