Style 6 Demo

HIPAA Notice Acknowledgment

Confirm you received our Notice of Privacy Practices.

Notice of Privacy Practices

Our Notice of Privacy Practices explains how Style 6 Demo may use and share your health information, and the rights you have over it.

A copy of our Notice of Privacy Practices is available from our front desk. Ask us and we'll give or email you one.

Signing this acknowledgment is optional. It only confirms you received the notice; it does not give permission for any use of your information beyond what the notice describes. You can still receive care if you prefer not to sign; just let our staff know.

Patient Name *

Email *

Who is signing this form? *

Patient (myself)

Parent or legal guardian

Other legal representative

Your full name *

Your authority to sign for the patient (for example, parent, court-appointed guardian or health care power of attorney) *

I received the Notice of Privacy Practices. *

By signing below, you confirm the information you gave is accurate to the best of your knowledge and you agree to sign this form electronically. Your electronic signature has the same effect as a handwritten one. You can ask Style 6 Demo for a paper copy of this form at any time.

Date *

Signature *

Your information is encrypted and transmitted securely under HIPAA.

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