{"id":283,"date":"2026-03-17T14:56:01","date_gmt":"2026-03-17T14:56:01","guid":{"rendered":"https:\/\/www.change-in-entropy.com\/?page_id=283"},"modified":"2026-03-17T14:56:22","modified_gmt":"2026-03-17T14:56:22","slug":"hipaa-acknowledgment-of-receipt-form","status":"publish","type":"page","link":"https:\/\/www.change-in-entropy.com\/index.php\/hipaa-acknowledgment-of-receipt-form\/","title":{"rendered":"HIPAA Acknowledgment of Receipt form"},"content":{"rendered":"\t\t
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HIPAA Acknowledgment of Receipt of Notice of Privacy Practices<\/h1>

Change in Entropy Hypnotherapy<\/strong>
Website:<\/strong> https:\/\/www.change-in-entropy.com\/<\/a>
Effective Date:<\/strong> March 17, 2026
Last Updated:<\/strong> March 17, 2026<\/p>

Practice Contact Information<\/strong>
Change in Entropy Hypnotherapy
2862 Change Street, Unit A
Los Alamos, NM 87544
Email: jennifer@change-in-entropy.com<\/a>
Phone: (907) 278-1180<\/p>

Patient Information<\/h2>

Patient Full Name:<\/strong> __________________________________________<\/p>

Date of Birth:<\/strong> _____________________________________________<\/p>

Address:<\/strong> _________________________________________________<\/p>

Phone:<\/strong> _________________________________________________<\/p>

Email:<\/strong> _________________________________________________<\/p>

Acknowledgment of Receipt<\/h2>

I acknowledge that I have received a copy of the Notice of Privacy Practices<\/strong> for Change in Entropy Hypnotherapy.<\/p>

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\u2019s legal duties.<\/p>

I understand that signing this form only confirms that I received the Notice of Privacy Practices. It does not<\/strong> mean that I authorize any use or disclosure of my information beyond what is permitted or required by law.<\/p>

Patient Signature:<\/strong> _________________________________________<\/p>

Date:<\/strong> ___________________________________________________<\/p>

Personal Representative, If Applicable<\/h2>

If signed by a personal representative, complete the following:<\/p>

Name of Personal Representative:<\/strong> _____________________________<\/p>

Relationship to Patient:<\/strong> ____________________________________<\/p>

Authority to Act for Patient:<\/strong> _________________________________<\/p>

Signature of Personal Representative:<\/strong> _________________________<\/p>

Date:<\/strong> ___________________________________________________<\/p>

Refusal to Sign Acknowledgment<\/h1>

For Practice Use Only<\/strong><\/p>

The patient or personal representative was provided with the Notice of Privacy Practices on the date below but did not sign this acknowledgment.<\/p>

Date Notice Provided:<\/strong> ______________________________________<\/p>

Method of Delivery:<\/strong>
\u2610 In person
\u2610 Email
\u2610 Mail
\u2610 Portal
\u2610 Other: ______________________________________<\/p>

Reason acknowledgment not obtained, if known:<\/strong>
\u2610 Patient refused to sign
\u2610 Patient unable to sign
\u2610 Patient left before signing
\u2610 Emergency situation
\u2610 Other: ______________________________________<\/p>

Staff Member Name:<\/strong> _______________________________________<\/p>

Staff Signature:<\/strong> __________________________________________<\/p>

Date:<\/strong> ___________________________________________________<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"

HIPAA Acknowledgment of Receipt of Notice of Privacy Practices Change in Entropy HypnotherapyWebsite: https:\/\/www.change-in-entropy.com\/Effective Date: March 17, 2026Last Updated: March 17, 2026 Practice Contact InformationChange in Entropy Hypnotherapy2862 Change Street, Unit ALos Alamos, NM 87544Email: jennifer@change-in-entropy.comPhone: (907) 278-1180 Patient Information Patient Full Name: __________________________________________ Date of Birth: _____________________________________________ Address: _________________________________________________ Phone: _________________________________________________ Email: _________________________________________________ Acknowledgment […]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-283","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/pages\/283","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/comments?post=283"}],"version-history":[{"count":4,"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/pages\/283\/revisions"}],"predecessor-version":[{"id":287,"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/pages\/283\/revisions\/287"}],"wp:attachment":[{"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/media?parent=283"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}