ed a copy of the Baylor College of Medicine
Acknowledgment of Receipt
of Privacy Notice
y signing this form, you are agreeing that you have receiv
rivacy Notice, which describes how we use and disclose your health information. You have the right to
efuse to sign this Acknowledgment, in which case we must document our good faith effort to obtain
our acknowledgment and the reason why it was not obtained.
eceipt of Privacy Notice acknowledged by:
elationship to patient:
Patient, spouse, legal representative, or beneficiary (Patient’s spouse may authorize disclosure of
patient’s health information only when the health information is for the sole purpose of processing
an application for health insurance, for enrollment in a health care service plan or an employee
benefit plan, and where patient is to be an enrolled spouse or dependent under the policy or plan).