Acknowledgment of Receipt of Notice of Privacy Practices

I acknowledge that I have received a copy of Provider's Notice of Privacy Practices with the effective date of [insert date].


_____________________________________                 ______________________
Signature of Patient/Patient Representative                           Date


_____________________________________
Relationship to Patient









[Note: Providers are required to make good faith efforts to obtain acknowledgement that each patient has received their Notice of Privacy Practices. The regulation does not specify how that acknowledgement is documented. This example form is meant to serve as an example of one way that a provider could document the required acknowledgement.]

(Document provided to MIEC policyholders with permission from
Physician Insurers Association of America)

 

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