Patient Acknowledgement and Consent Form Medicare Supplier Standards HIPAA Privacy Standards Patient Acknowledgment and Consent Form: I, the undersigned, acknowledge that I have received a copy or the link to the HIPAA Privacy Regulations and the Medicare Supplier Standards. I understand these documents provide information regarding my rights and responsibilities concerning my healthcare and the protection of my personal health information. By checking the box below, I agree that my printed name shall serve as my legal signature, affirming my acknowledgment and consent. I agree to the use of my printed name as my signature and confirm that I have received the HIPAA Privacy Regulations and Medicare Quality Standards. * I Agree Printed Name: * Date of Birth: * MM DD YYYY Date Signed: * MM DD YYYY Thank you!
