US Medical Forms · 中文
隐私惯例通知确认书
⚠ 这是参考翻译，帮助您了解典型表格内容。这不是官方文件。您的医疗提供者的实际表格可能有所不同——请务必签署提供者自己的版本。
患者信息 / Patient Information
| English | 中文 | English — Help | 中文 — Help |
|---|---|---|---|
| Patient Full Name | 患者全名 | 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. | 本次就诊相关患者的法定全名。如果您代表他人签署，请在此填写该人的姓名——而非您自己的姓名。 |
| Date of Birth | 出生日期 | The patient's date of birth. Used alongside the name to confirm the correct patient record in the provider's system. | 患者的出生日期。与姓名一起用于在提供者系统中确认正确的患者记录。 |
| Provider / Clinic Name | 提供者 / 诊所名称 | 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. | 您正在确认其隐私惯例通知的医疗机构或诊所的名称。这标识了向您发放NPP的提供者。 |
| Date Notice of Privacy Practices Received | 收到隐私惯例通知的日期 | 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. | 您从该提供者收到隐私惯例通知的日期。通常是今天的日期——即您就诊的日期。这确立了您何时被告知提供者的隐私惯例。 |
确认声明 / Acknowledgment Statement
| English | 中文 | English — Help | 中文 — Help |
|---|---|---|---|
| I Acknowledge Receipt of the Notice of Privacy Practices | 我确认已收到隐私惯例通知 | 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. | 通过在此处签署首字母或打勾，您确认您已收到隐私惯例通知（NPP）——该文件说明了此提供者如何收集、使用和可能共享您的受保护健康信息（PHI）。签署并不意味着您同意提供者的隐私政策；仅表示您已收到文件。HIPAA要求受覆盖的提供者真诚地尝试获得此确认。 |
签名 / Signature
| English | 中文 | English — Help | 中文 — Help |
|---|---|---|---|
| Signature | 签名 | 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. | 您的手写或电子签名，确认您已收到隐私惯例通知。如果患者无法签署（例如，由于年龄或无行为能力），授权代表可以签署。 |
| Date Signed | 签署日期 | 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. | 您签署此确认书的日期。通常与您收到通知的日期相同——通常是您就诊的日期。 |
| Printed Name | 正楷姓名 | Your name printed clearly in block letters alongside your signature. This makes your signature readable and creates a clear record of who signed. | 在签名旁边用正楷字母清楚地印刷您的姓名。这使您的签名可读，并创建清晰的签署人记录。 |
| Relationship to Patient (If Signing for Someone Else) | 与患者的关系（如代他人签署） | 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. | 如果您代表患者签署——例如，您是为未成年子女签署的父母、法定监护人或个人代表——请在此填写您的关系。如果您是患者本人签署，请留空。 |
Last reviewed: September 2026