HIPAA Acknowledgement

HIPAA Acknowledgement

Spectra Health Clinics
Review Spectra Health's Notice of Privacy Practices

Review Spectra Health's Patient Bill of Rights
Patient Information
ARCHIVED Patient Name

First NameLast Name
Patient Name

First NameLast Name
patient name print
Patient Date of Birth

MonthDayYear
patient DOB print
ARCHIVED Date of Birth

MonthDayYear
Date
Acknowledgement and Signature
By signing this document, I am acknowledging that I have received or reviewed Spectra Health's Notice of Privacy Practices and the Patient Bill of Rights (effective January 26, 2004).

I understand that I may ask questions about the Notice of Privacy Practices and the Patient Bill of Rights at any time. Spectra Health participates in Blue Alliance through ND Blue Cross, and I can ask questions about this participation at any time.
Initials of Signer
I am the parent or legal guardian of the patient listed on this form:
ARCHIVED Patient or Legal Guardian Signature
Signature
Name of Parent/Legal Guardian
Relationship to Patient
parent name relationship print
Date Signed

MonthDayYear
Date
Should be Empty:

Patient Information