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Patient Acknowledgement Form


Looking for a Patient Acknowledgement Form template? Our form ensures patients understand and comply with clinic/hospital policies on privacy, payment, and cancellations.

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Document Description

This Patient Acknowledgement Form template ensures that patients acknowledge and understand the Privacy, Payment, and Cancellation Policies of a clinic or hospital. By signing the form, patients agree to the Notice of Privacy Policy, which explains how their medical information may be used or disclosed by the healthcare provider.

Patients also authorise the healthcare provider to release their medical information for healthcare, billing, insurance, and payment purposes, and to send electronic communication containing protected health information. Patients agree to pay for all charges for the treatment and/or consultation provided at the time of service, and understand that there are no refunds for prepaid treatments. Patients acknowledge and understand the cancellation policy of the healthcare provider. The form includes fields for the patient's name, signature, and date, and if the patient is under 18, the parent or guardian's name, signature, and date. This template can be used as a patient consent form and is available as a downloadable form.

How to use this Document?

Here are the steps on how to use the Patient Acknowledgement Form:

1. Read the Notice of Privacy Practices carefully to understand how the clinic/hospital uses and discloses your medical information.

2. Authorise the release of your medical information to help provide healthcare and handle billing, insurance, and payment.

3. Understand that all charges are due at the time of service, and there are no refunds on consultations and/or treatments.

4. Acknowledge and understand the cancellation policy of the clinic/hospital.

5. If you are a minor, have your parent/guardian sign the form.

6. Sign the form to acknowledge and agree to adhere to the Privacy, Payment, and Cancellation Policies of the clinic/hospital.

It is important to carefully read and understand the policies outlined in the form before signing it. By signing the form, you acknowledge that you have received, read, and understood the Notice of Privacy Practices, agree to the release of your medical information, and agree to adhere to the clinic/hospital's payment and cancellation policies. If you are a minor, your parent/guardian must sign the form on your behalf.



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