Privacy Practices Acknowledgement

Additional Disclosure Authorization

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby
specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified
below. (I understand that the default answer is “NO”; Without Indicating “YES” in answer to each
individual question; personal protected health information (PHI) cannot be shared with anyone unless otherwise allowed
by HIPAA.)

Spouse Only
Any Member of my immediate family: (Spouse, Children, Children’s Spouses)
Any member of my extended family: (Parents, Grandchildren)
Other:
Name of Patient
Patients personal representative:
Representative’s Telephone Number
Date

Acknowledgement Not Obtained

Provided Prior to Treatment?
Date Statement Provided

Reason for not obtaining Signature

Other Reason: