PATIENT ACKNOWLEDGMENT FORM

PATIENT ACKNOWLEDGMENT FORM
For the Facility checked below:
 HyperbaRXs at Kennestone (d.b.a. Cobb Hyperbaric Medicine)
 HyperbaRXs at Lithonia (d.b.a. DeKalb Hyperbaric Medicine & Wound Care Center)
 HyperbaRXs at Northside Forsyth (d.b.a. North Georgia Center for Hyperbaric Medicine & Wound Care)
 HyperbaRXs at Saint Joseph’s (d.b.a. Hyperbaric Medicine of North Atlanta)
Patient’s Name: ____________________________________________ Date of Birth: ______________
Previous Name: ____________________________________________
I understand that the patient’s health information is private and confidential. I understand that Hyperbaric
Physicians of Georgia and this Facility work very hard to protect the patient’s privacy and preserve the
confidentiality of the patient’s personal health information.
I understand that Hyperbaric Physicians of Georgia and this Facility may use and disclose the patient’s personal
health information to help provide health care to the patient, to handle billing and payment, and to take care of
other health care operations. In general, there will be no other uses and disclosures of this information unless I
permit it. I understand that sometimes the law may require the release of this information with my permission.
These situations are very unusual. (One example would be if a patient threatened to hurt someone.)
Hyperbaric Physicians of Georgia and this Facility have a detailed document called the “Notice of Privacy
Practices”. It contains more information about the policies and practices protecting the patient’s privacy and is
available to all patients. I understand that I have the right to read the “Notice of Privacy Practices” before
signing this Acknowledgment.
Hyperbaric Physicians of Georgia and this Facility may update this Acknowledgment and “Notice of Privacy
Practices”. If I ask, Hyperbaric Physicians of Georgia or this Facility will provide me with the most current
“Notice of Privacy Practices”.
Within the “Notice of Privacy Practices” is contained a complete description of my privacy/confidentiality rights.
These rights include, but aren’t limited to, access to my medical records, restrictions on certain uses; receiving
an accounting of disclosures as required by law; and requesting communication be by specified methods of
communications or alternative location.
Hyperbaric Physicians of Georgia and this Facility have established procedures which help them meet their
obligations to patients. These procedures may include other signature requirements, written acknowledgments,
and authorizations; reasonable time frames for requesting information; charges for copies and non-routine
information needs, etc. I will assist Hyperbaric Physicians of Georgia and this Facility by following these
procedures if I choose to exercise any of my rights described in the “Notice of Privacy Practices”.
My signature below indicates that I have been given the chance to review a current copy of Hyperbaric
Physicians of Georgia and this Facility’s “Notice of Privacy Practices”.
__________________________________________________________
Signature
________________________
Date and Time
________________________________________________________________________________
Relationship to patient if signed by anyone other than the patient
(Parent, legal guardian, personal representative, etc.)