Acknowledgement of Receipt of Notice of Privacy Practices / Communication Authorization

Method of Disclosure

Patient Name – First

Last

Patient Date of Birth

Please provide all patient contacts that may be used for communications from Independence Women's Clinic:

Cell Phone

Text

Email Address

Permission to Disclose Protected Health Information

I give Independence Women's Clinic permission to disclose my protected health information to the following individuals involved in my health care and/or payment for health care goods and services.

Name

Relationship

Contact No.

Name

Relationship

Contact No.

Name

Relationship

Contact No.

I acknowledge that I have received a copy of Independence Women's Clinic’s
Notice of Privacy Practices with the effective date of July 1, 2015.

Patient First Name

Last

Patient Date of Birth

Name of Guarantor/Legal
Representative

Relationship to Patient

Patient/Guarantor/Legal Representative Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.

Date

LuxSci helps ensure HIPAA-compliance for email and web services.