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US Medical Forms · English

Notice of Privacy Practices Receipt

Note: This is a reference translation to help you understand a typical form. It is not an official document. Your provider's actual form may differ — always sign the provider's own version.
When you receive this form At your first visit to any new healthcare provider covered by HIPAA. The provider hands you their Notice of Privacy Practices and asks you to sign or initial this short form confirming you received it.
What to bring or have ready Nothing specific — the provider hands you the Notice at the visit. Take a few minutes to read it before signing this acknowledgment. You may ask for a copy to keep for your records.

Patient Information

English What this field means
Patient Full Name The full legal name of the patient whose care this visit relates to. If you are signing on behalf of someone else, write that person's name here — not your own.
Date of Birth The patient's date of birth. Used alongside the name to confirm the correct patient record in the provider's system.
Provider / Clinic Name The name of the healthcare practice or clinic whose Notice of Privacy Practices you are acknowledging. This identifies which provider issued the NPP you received.
Date Notice of Privacy Practices Received The date you received the Notice of Privacy Practices from this provider. Usually today's date — the date of your visit. This establishes when you were informed of the provider's privacy practices.

Acknowledgment Statement

English What this field means
I Acknowledge Receipt of the Notice of Privacy Practices By initialing or checking this box, you confirm that you received the Notice of Privacy Practices (NPP) — the document that explains how this provider collects, uses, and may share your protected health information (PHI). Signing does not mean you agree with the provider's privacy policies; it means only that you received the document. HIPAA requires covered providers to make a good-faith effort to obtain this acknowledgment.

Signature

English What this field means
Signature Your handwritten or electronic signature confirming you received the Notice of Privacy Practices. If the patient cannot sign (for example, due to age or incapacity), an authorized representative may sign.
Date Signed The date you are signing this acknowledgment. This is typically the same as the date you received the Notice — usually the date of your visit.
Printed Name Your name printed clearly in block letters alongside your signature. This makes your signature readable and creates a clear record of who signed.
Relationship to Patient (If Signing for Someone Else) If you are signing on behalf of the patient — for example, you are a parent signing for a minor child, a legal guardian, or a personal representative — write your relationship here. Leave blank if you are the patient signing for yourself.

Related guides

← All Forms US Guides Reception Phrasebook State Directory

Sources

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Last reviewed: September 2026