Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices (HIPAA)

You may refuse to sign this Acknowledgement

I have received a copy of this Notice of Privacy Practices.

Patient Name(*)

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Email address(*)

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Patient Record of Disclosure

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's home.

I wish to be contacted in the following manner (check all that apply):

Home Telephone

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Okay to leave message with instructionsOkay to leave message with call-back number onlyInvalid Input

Work Telephone

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Okay to leave message with instructionsOkay to leave message with call-back number onlyInvalid Input

Written Communication

Okay to mail to home addressOkay to mail to work/office addressInvalid Input

SSN

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Date of Birth(*)

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Same Day Appointments & Walk-Ins Welcome

Most Plans & AHCCCS Accepted

Open Saturdays in Three Convenient Locations

Women's Health, Men's Health & Well Child Exams

On Site Blood Draws & Lab Work

Acknowledgement of Receipt of Notice of Privacy Practices (HIPAA)

Patient Record of Disclosure