Acknowledgement of Notice of Privacy Practices:

A statement that the patient has received, read, and understands the practice's Notice of Privacy Practices (NPP), which outlines how their protected health information (PHI) will be used and disclosed.  

Consent to Use and Disclosure: The patient's consent for the practice to use and disclose their PHI for treatment, payment, and healthcare operations.

Authorization for Specific Disclosures (if applicable): A section for the patient to authorize the release of their PHI to specific individuals (e.g., family members) or for specific purposes (e.g., marketing, research). This should be a separate, explicit authorization

Patient Rights: A clear explanation of the patient's rights under HIPAA, such as the right to request restrictions on how their information is used, the right to inspect and copy their medical records, and the right to revoke their consent

Signature and Date: A space for the patient or their authorized representative to sign and date the form.