HIPAA Privacy Acknowledgment Form | Golden Grace Health Care LLC

Client details

Client Name *Date of Birth

I acknowledge that I have received and reviewed a copy of Golden Grace Health Care LLC's Notice of Privacy Practices, which describes how my health information may be used and disclosed.
I understand that this notice includes my rights regarding my health information and the agency's legal duties to protect my privacy under the Health Insurance Portability and Accountability Act (HIPAA).
I understand that Golden Grace Health Care LLC may use or disclose my health information for the purpose of treatment, payment, and healthcare operations as described in the Notice of Privacy Practices.
I understand that I may request restrictions on how my information is used or disclosed and that the agency is not required to agree to those restrictions.
I understand that I may revoke this acknowledgment in writing at any time, except to the extent that the agency has already acted based on my prior consent.

I have read and understand the information stated above.Relationship (if signed by a representative)

Client or Representative/Relationship Signature *

By signing, you agree this electronic signature is the legal equivalent of your handwritten signature.

Date

Agency Representative Signature

By signing, you agree this electronic signature is the legal equivalent of your handwritten signature.

Date