HIPAA Notice of Privacy Practices Acknowledgment Form

Speech Therapy Services Privacy Agreement

I, _________________________________ (print patient name), acknowledge that I have received a copy of [Practice Name]'s Notice of Privacy Practices.

Understanding of Rights

I understand that this document informs me of:

• How my protected health information (PHI) may be used and disclosed
• My rights regarding my PHI
• The speech therapy practice's legal duties concerning my health information

Consent for Communication

I authorize [Practice Name] to communicate with me regarding my care via:

• Phone: ________________________
• Email: ________________________
• Text message
• Mail to home address

Authorization for Information Sharing

I permit my health information to be shared with:

1. Primary Care Physician: _____________________
2. Other Healthcare Providers: _________________
3. Family Members (specify): ___________________

Signature Section

Patient/Guardian Signature: ____________________ Date: _______________

If signed by someone other than patient: Printed Name: _____________________ Relationship to Patient: ___________________

For Office Use Only

We attempted to obtain written acknowledgment but could not because:

• Individual refused to sign
• Communication barrier prohibited obtaining acknowledgment
• Emergency situation prevented obtaining acknowledgment
• Other (specify): _______________________

Staff Signature: ___________________ Date: _______________