Patient HIPAA Acknowledgement & Designation Disclosure Form

Acknowledgment of Practice’s Notice of Privacy Practices:

By subscribing my name below, I acknowledge that Neurovations Clinic has provided a copy of the Notice of Privacy Practices (NPP) and that I have read (or had the opportunity to read if I so chose) and understand my rights and ask questions regarding my rights and receive answers to my satisfaction and agree to its terms.

Name of Patient

Signature of Patient

Date

Designation of Certain Relatives, Close Friends, and other Caregivers as my Personal Representative

I agree that the practice may disclose certain of my health information to a Personal Representative of my choosing, since such person is involved with my health care or payment relating to my health care. In this case, the Physician Practice will disclose only information that is directly relevant to the person’s involvement with my health care or payment relating to my health care.

Print Name

Date of Birth

Phone

Print Name

Date of Birth

Phone

Print Name

Date of Birth

Phone

acting on behalf of my minor son/daughter

Parent/Guardian

Name of Patient

As legal Personal Representative in all matters. If the representative is a court-appointed legal guardian, a copy of court documents must be provided and kept in medical records.

Request to Receive Confidential Communications by Alternative Means

I understand that as part of my health care and treatment, Neurovations Clinic may need to reach me by phone. As provided by Privacy Rule Section 164.522(b),

I DO hereby authorize and request that the Practice make all communications to me by the alternative means that I have listed below regarding instructions, procedures, clinical test results, billing and/or appointment needs, etc.

Home/Cell Telephone Number

Preference for leaving messages

Leave a voicemail with detailed information

E-mail to address listed information

I DO NOT authorize Neurovations Clinic to contact me to leave a message on my home or cell phone regarding communication of my health care/treatment such as instructions for procedures, clinical test results, billing and/or appointment needs, etc. I understand that by selecting this option it may result in delayed communication of pertinent treatment information such as medication changes, appointment confirmations, billing communications or clinical call backs. I understand that I will be responsible for making appointments to obtain this information. If you have any questions regarding this notice or any of our office policies, please contact the Practice Administrator at 321-285-2369 Thank you.

Thanks for submitting!