HIPAA OMNIBUS RULE

PATIENT ACKNOWLEDGEMENT FORM FOR RECEIPT OF NOTICE OF PRIVACY PRACTICES CONSENT/ LIMITED AUTHORIZATION RELEASE FORM

You may refuse to sign this acknowledgement & authorization: In refusing we may not be allowed to process your insurance clams.

Date:
The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.

Please print name of Patient:
Please sign Patient / Guardian of Patient
Legal Representative Guardian:
Relationship of Legal Representative / Guardian:

HOW DO you WANT TO BE ADDRESSED WHEN SUMMONED FROM RECEPTION AREA:
First Name Only
Proper Surname
Other

PLEASE LIST ANY OTHER PARTIES WHO ARE ACTIVELY INVOLVED IN YOUR HEALTH CARE AND WHO CAN HAVE ACCESS TO
YOUR HE ALTH INFORMATION: (This includes step parents. grandparents and any care takers who can have access to this patient's records):

Name:	Relationship:
Name:	Relationship:

I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA:
Cell Phone Confirmation
Text Message to my Cell Phone
Home Phone Confirmation
Email Confirmation
Work Phone Confirmation
Any of the Above

I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA:
Cell Phone Confirmation
Text Message to my Cell Phone
Home Phone Confirmation
Email Confirmation
Work Phone Confirmation
Any of the Above

I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO on behalf of this Healthcare Facility via:
Phone Message
Text Message
Email
Any of the Above
None of the Above (opt out)

In signing this HIPAA Patient Acknowledgment Form, you acknowledge and authorize thot this office may recommend products or services to promote your improved health.
This office may or may not receive third patty remuneration from these affiliated companies. We, under HIPAA Omnibus Rule, provide you 'this information with your knowledge and consent