Fillable Printable Acknowledgement of Receipt Template
Fillable Printable Acknowledgement of Receipt Template
Acknowledgement of Receipt Template
I want NO ONE to receive m
y
Personal Health Information exce
p
t m
y
self.
I
g
ive
p
ermission to leave a verbal messa
g
e at m
y
p
ersonal residence.
YesNo
I
g
ive
p
ermission to leave a messa
g
e re
g
ardin
g
m
y
a
pp
ointment on m
y
voicemail.
YesNo
I
g
ive NowCare
p
ermission to release an
y
ur
g
ent care notes to m
y
p
ersonal
p
h
y
sician.
YesNo
I
g
ive
p
ermission to call me at work.Work Phone:
YesNo
Last Name:
First Name:
Birthdate:
I have been given a copy of Bayview Physicians Group’s Notice of Privacy Practices, version effective September 23, 2013. I
consent to the uses and disclosures of my health information as outlined in the Notice.
If acknowledgment of receipt of the Notice of Privacy Practices is not obtained from the patient or the patient’s representative, please explain
your efforts to obtain acknowledgment and the reason you could not obtain it:
Representative's Name (Print)Representative's Signature
Date
Privacy Options
Date
Lname, Fname
I request the following person(s) BE ALLOWED to access my Personal Health Information:
I request the following person(s) NOT
BE ALLOWED to access my Personal Health
Information:
Communications
If you are signing on behalf of the patient, please complete this section:
Please Sign
Patient's SignaturePatient's Name (Print)
*** Office Use Only ***
Reason Patient Cannot Sign
Acknowledgement of Receipt
