Patient Acknowledgement and Con..nt, Form
EffectiveApri114, 2003, the:aew
,lIS tht.lJealth
of 1996
that this oftice'cmDply' .
. rules teprdiDg the maiutenance' of the privaq of yGur iDforma..
tion that we have collected and wiD COIJ.ectin the future. . .
.
To comply with one of HlPAA's requirements, we a:re giv:ingyou a copy of our Notice ofPrivaq Practices. This Notice
of Pri:vaey Practices contains the information thai HIPAA requires us to d.iscloae regarding our privacy practicea. '
Existing Michigan La,v requires (in addition to
to obtain your writte:nac1mowJ.edament, diacuased above)
us to first obtam your written co:nsent prior to disclosing any of your iDfQl'lDation·Ct.'IQ8Pt for ourdisclO8t11'$Sin c:ortolCtion
with: 8 defense toa claim cballenging our professional eompetence; a review
a·claim
of,
fees; 8 third party ))83'el"s examination of our records; ,8 court
as part Of s' cri:lIiibal inve&tiptkQl; BIl .....tijicati.OJl
of 8 dead body; 8 licensure investigation; or a child abaselnegJ.ect investigation.'
.
From time to time it may be
for us'to make
ineon:nection with your treatment. FOr eumple, we lIlaY make B referral
'
,
other health care profeasianal, provide
a specimen to a laboratory for teatillg or
.. ofyourinMrmation in connection with providin,g or
coordinating your t r e a t m e n t . '
.
("HIPAAD) requires
MAY WE LEAVE MESSAGE ON ANS4llEIUNG'MACHINE (please cirCle) yes
no
Patient Acknowledge.....
Plea.se sign. this form below under the heading "acknowledgement'" to acknowledge that you have toda;y
COP:J ofour notice ofprivacy practices.
(J
I acknowledge that,! have today received a copy of the Notice of Privacy Praetieee.
Patient Signature
Patient Name (please print)
Date: _ _ _ _ _ _ _ _ __
Far offIce use 0Dly
Patient Retu.ed to Bien
The following circumstances prohibited the patient from signing the Acknowledgment:
An emergency situation prevented the patient from signing the .Acknowledgement.
Office.Personnel (signature)
Office Personnel (print Dame)
____________________
Please sip. this form below under the headi,ng "COnH1J.t" to corr..sen.t to our cli8closures ofyour i:n.forrnatittll
deem n,ecessory in orrltu to provide you with prop61' treatment.
we
I COllSeJlt to your d:iselosuresof my informatiCD'lt which you deem. are necessary inconnecti.on with my treatment..
I understand that such. disclosures may not be Of th& type listed above.
PatientSignature
Date: ______________
Patient Name (pleue print)