
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):