Acknowledgement of Receipt of Privacy Notice Form

Client Name:                                                           

Date of Birth:

I have received this practice’s Notice of Privacy Practices written in plain language. The notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise those rights and the practice’s legal duties with respect to my protected health information.

I understand that this practice reserves the right to change the terms of its Privacy Practices and to make changes regarding all protected health information that it maintains. I understand that I can obtain this practice’s current Notice of Privacy Practices on request.

Client or Personal Representative* Signature                                     Date        

* If signed by Personal Representative, state relationship to client: