Patient Acknowledgement of Notice of Privacy Practices Consent

I have read the Notice of Privacy Practices of Mountain Valley Medical Clinic (MVMC)
and understand that as a patient I have the right to limit the use and disclosure of my
personal health information (PHI.)

 

I authorize MVMC to release my PHI to another healthcare provider for treatment or payment
of my healthcare needs. I understand that should a third party request my PHI I will be required
to come into the office and sign an authorization for MVMC authorizing the release of my PHI.

 

I authorize MVMC to leave messages at my home or other designated telephone numbers confirming
appointments with the providers of MVMC. I also consent to the clinical staff leaving a message dealing
with negative laboratory study results.

 

I hereby authorize MVMC to discuss my PHI with the following family members or entrusted personnel:

 

NAME:                                                                RELATIONSHIP:                                             TELEPHONE:

 

_________________________               _________________________               _________________________

 

_________________________               _________________________               _________________________

 

_____ I do not give my consent for any of my personal healthcare information being disclosed with anyone
other than myself. I do give my consent for my personal healthcare information being disclosed to another
healthcare provider for treatment and payment of my healthcare needs.

 

This request is effective as of today and will expire one year from today.

I understand that I may revoke this consent at anytime by submitting a written request.

__________________________________________________________                                                         __________________

Patient or Legal Guardian Signature                                                                                                             Date

 

 

__________________________________________________________                                                         __________________

Witness Signature                                                                                                                                       Date

Acknowledgement of Receipt of Notice of Privacy Practices

 

I, ___________________________________________________________________________________

Patient Name

 

 

Have received a copy of Mountain Valley Medical Clinic

Notice of Privacy Practices

__________________________________________________________                                                         __________________

Patient or Legal Guardian Signature                                                                                                                 Date

~Complete below if the patient does not sign the acknowledgement~

• Good faith effort was made to have the patient sign the acknowledgement of receipt of the Notice of Privacy Practices. The patient declined to sign the acknowledgement.

• The Notice of Privacy Practices was given to the patient.

• Notice of Privacy Practices was given to the patient’s representative

• Notice of Privacy Practices was declined by the patient, who was informed that they may have access to the Notice of Privacy Practices at any time in the future

__________________________________________________________                                                         __________________

Signature of Practice Staff Member                                                                                                                                Date