Acknowledgement of Receipt of "Notice of Privacy Practices"

The federal government mandated that as of April 14, 2003 all health care patients are to receive from their clinicians a notice (hereafter referred to as "Notice") regarding the protection of their private health care information in compliance with the Health Insurance Portability and Accountability Act ("HIPAA") Privacy Rule (45 C.F.R. parts 160 and 164).

This form documents that Dr. Krapu has given you the "Notice" that is required. HIPAA covers what is called "protected health information" (PHI) that is used for treatment, payment, and health care operations. PHI is information in your health record that could identify you.

The Notice contains basic information about:

1. How your PHI may be used and disclosed for treatment, payment and health care operations (these terms are defined in the Notice)
2. Which uses and disclosures require authorization from you and which don't
3. How you may revoke an authorization you have made
4. Certain rights you have to restrict use and disclosure of PHI, to receive confidential communications by alternative means and at alternative locations, to inspect and copy your records, to amend your records, to have an accounting of disclosures
5. A list of my duties to protect the privacy of your PHI, my right to change the privacy policies and practices described in the Notice, and how I will inform you of changes
6. What you can do if you have any complaints about violations of your privacy rights, about decisions about access to your records I may make
7. Any restrictions and limitations you or I wish to put on the use and disclosure of your PHI.

The Privacy Notice is four pages long. Generally, this Notice is given to a client (or their parent if the client is a minor) via email along with a confirmation of the first consultation. If you don't have email it is given at the first visit unless there is good reason to delay. A copy of the Notice is available by request and is on my website (http://www.krapu4.com/psy/HIPPA_PrivacyNotice.htm). This page documents that I have given you a copy of the Notice.

I acknowledge that Dr. Krapu has given me a copy of the Privacy Notice either by email, US Mail, or in person, (version dated 2/26/03) as required by the federal government's HIPAA legislation.

Date _____________________
________________________	________________________
Print Patient's Name	Signature
________________________	________________________
Print name of Parent or Legal Guardian if patient is a minor, Personal Representative	Signature
Describe your role in regard to the patient and/or the authority by which the person is signing for the Patient:

(version 2/26/03)