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Notice of Privacy Practices Acknowledgement Form Mobile App

Get closer to going paperless in your health care practice with an easy mobile app for patients to sign and date your privacy practices acknowledgement form.

This digital form, to acknowledge compliance with HIPAA and HIPAA privacy practices, can be customized by any health insurance or healthcare provider and used by patients directly on a smartphone, tablet or PC. Easy check mark boxes and fillable forms to sign and date will help to streamline patient check-in at hospitals, family medicine practices, dental offices or any health care provider.

Get your patient's acknowledgement of your privacy practices, acts that their doctor may potentially be performing in the future and their understanding that their health information has been taken into account and will be opted by the health care provider if it will be disclosed to other physicians.

Save your digital privacy practice acknowledgement forms to the GoCanvas Cloud as well as a PDF file for your record-keeping ease.

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

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Take a peek inside the Notice of Privacy Practices Acknowledgement Form Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    I understand that I have certain rights to privacy regarding my protected health information.

  • Ico statictext

    I understand that this information can and will be used to:

  • Ico statictext

    Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who m...

  • Ico statictext

    Obtain payment from third-party payers.

  • Ico statictext

    And conduct normal healthcare operations such as quality assessments and physician certifications.

  • Ico statictext

    I have received, read and understood your Notice of Privacy Practices,

  • Ico statictext

    containing a more complete description of the uses and disclosures of my health information.

  • Ico statictext

    I understand that this organization has the right to change its Notice of Privacy Practices from ...

  • Ico statictext

    And that I may contact this organization at any time to obtain a current copy of the Notice of Pr...

  • Ico statictext

    I understand that I may request in writing that you may restrict how my private information is us...

  • Ico statictext

    to carry out treatment, payment or health care operations.

  • Ico statictext

    I also understand you are not required to agree to my requested restrictions,

  • Ico statictext

    but if you do agree then you are bound to abide by such restrictions.

  • Ico textbox

    Patient Name

  • Ico textbox

    Relationship to Patient

  • Ico signature


  • Ico date


  • ...and More!

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