Priority Number

HIPAA Patient Acknowledgement of Receipt of Privacy Practices


Satisfy HIPAA compliance obligations as a healthcare provider

Complies with new HIPAA rules, effective September 23, 2013

As a health care provider, you are required by HIPAA to adopt policies and procedures to protect the confidentiality of your patients’ health information. This includes giving patients written notice on how you may use and disclose their protected information and having policies in place to address patient privacy complaints. This attorney-approved form satisfies your HIPAA obligations by documenting compliance.


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  • Meets all required elements for a valid patient acknowledgement under HIPAA.
  • Deadline to comply with new HIPAA rules has passed - September 23, 2013.

Product Specifications:

  • Size: 8 1/2" x 11"
  • 200 forms per pack