HIPAA HIPAA ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES *Please Note: I may refuse to sign this acknowledgment. I have been offered and/or received a copy of Drs. Kirkpatrick and Lai's Notice of Privacy Practices. I understand that my PHI (Protected Health Information) can and will be used for purposes of treatment and for payment from both myself and/or third party. I understand that I may request a copy of the privacy policies at any time.* Printed Patient Name:Date MM slash DD slash YYYY HiddenPatient Signature (18+ years of age) Patient Signature (18+ years of age)HiddenParent/Guardian Signature* Parent/Guardian Signature*Relationship to Patient* Name and relationship for each person to whom you authorize release of information to: Expires 3 Years from Initial Signature*Date: MM slash DD slash YYYY Expires when patient reaches the age of 18*Date of Age 18: MM slash DD slash YYYY
