HIPAA Acknowledgment of Receipt of Notice of Privacy Practices
Change in Entropy Hypnotherapy
Website: https://www.change-in-entropy.com/
Effective Date: March 17, 2026
Last Updated: March 17, 2026
Practice Contact Information
Change in Entropy Hypnotherapy
2862 Change Street, Unit A
Los Alamos, NM 87544
Email: [email protected]
Phone: (907) 278-1180
Patient Information
Patient Full Name: __________________________________________
Date of Birth: _____________________________________________
Address: _________________________________________________
Phone: _________________________________________________
Email: _________________________________________________
Acknowledgment of Receipt
I acknowledge that I have received a copy of the Notice of Privacy Practices for Change in Entropy Hypnotherapy.
I understand that the Notice of Privacy Practices explains how my protected health information may be used and disclosed, my rights regarding that information, and the practice’s legal duties.
I understand that signing this form only confirms that I received the Notice of Privacy Practices. It does not mean that I authorize any use or disclosure of my information beyond what is permitted or required by law.
Patient Signature: _________________________________________
Date: ___________________________________________________
Personal Representative, If Applicable
If signed by a personal representative, complete the following:
Name of Personal Representative: _____________________________
Relationship to Patient: ____________________________________
Authority to Act for Patient: _________________________________
Signature of Personal Representative: _________________________
Date: ___________________________________________________
Refusal to Sign Acknowledgment
For Practice Use Only
The patient or personal representative was provided with the Notice of Privacy Practices on the date below but did not sign this acknowledgment.
Date Notice Provided: ______________________________________
Method of Delivery:
☐ In person
☐ Email
☐ Mail
☐ Portal
☐ Other: ______________________________________
Reason acknowledgment not obtained, if known:
☐ Patient refused to sign
☐ Patient unable to sign
☐ Patient left before signing
☐ Emergency situation
☐ Other: ______________________________________
Staff Member Name: _______________________________________
Staff Signature: __________________________________________
Date: ___________________________________________________