Patient Acknowledgment Form | ThriveWell Health

Draft template. Intended as a starting point for your intake paperwork (paper or portal-based). Have legal counsel confirm the language and workflow, including how it is retained in the patient's record.

ThriveWell Health is required by the Health Insurance Portability and Accountability Act (HIPAA) to provide patients with a Notice of Privacy Practices describing how the Practice may use and disclose protected health information (PHI), and to make a good faith effort to obtain the patient's (or personal representative's) written acknowledgment of receipt.

By signing below, I acknowledge that:

I have been offered a copy of ThriveWell Health's Notice of Privacy Practices.
I have had the opportunity to review the Notice and ask questions about its contents.
I understand that the Notice describes how my health information may be used and disclosed, and describes my rights regarding that information.
I understand that ThriveWell Health may update its Notice of Privacy Practices from time to time, and that an updated copy will be made available to me.

Patient Name (Print)

Date of Birth

Signature of Patient / Legal Guardian or Personal Representative

Signature

If signing on behalf of patient, relationship to patient

Date Signed

For Office Use Only — Good Faith Effort Documentation

Complete this section only if the Practice was unable to obtain the patient's signature.

Reason acknowledgment could not be obtained

Staff Member Name

Date

This form should be retained in the patient's medical record in accordance with ThriveWell Health's record retention policy and applicable North Dakota and federal requirements.

Patient Acknowledgment of Receipt

For Office Use Only — Good Faith Effort Documentation