WRITTEN ACKNOWLEDGEMENT OF RECEIPT OF HIPAA PRIVACY NOTICE 

 

(Please print this form and bring it with you to your initial appointment)

 

 

 

      I, __________________________________, have read and received a copy of the 

                 (Name of Client or Guardian)

 

                                                                        HIPAA Privacy Practices Notice from Janie Zeitlin, RDN, CDN ________________

                                                                                                                                                                                     (Date)

 

 

 

      _________      I authorize Janie Zeitlin, RDN, CDN and nutrition personnel to leave messages on

       (Initial)        my voicemail and/or speak with members of my household to confirm appointments.

 

 

       _________      I authorize Janie Zeitlin, RDN, CDN to disclose my personal health information to

       (Initial)        any individual(s) present during the counseling session.

 

 

       _________      I authorize Janie Zeitlin, RDN, CDN and nutrition personnel to disclose my personal

       (Initial)        health information to another healthcare provider for treatment purposes.

 

 

       _________      I authorize Janie Zeitlin, RDN, CDN and nutrition personnel to disclose my personal

       (Initial)         health information to the following individual(s):

 

 

       1) ______________________________      ______________________________     ______________________________  

                          (Name)                                   (Phone Number)                                 (Relationship)

​

       2) ______________________________      ______________________________     ______________________________  

                          (Name)                                   (Phone Number)                                (Relationship)

 

       3) ______________________________      ______________________________     ______________________________  

                          (Name)                                   (Phone Number)                                (Relationship)

 

 

 

 

        Address: ______________________________________________________________________________________  

 

        Phone:   ___________________________________  Alternate Phone: ___________________________________

 

       

       

        DOB:      ___________________________________

                             

       

        For Office Purposes Only:

 

        Written acknowledgement confirming receipt of HIPAA Notice could not be obtained:

         

        _________  Individual refused to sign                                _________  Other (Specify):