Knowledgebase-HIPAA Training Acknowledgment Form

Information Product

Title:HIPAA Training Acknowledgment Form
Summary:A form to acknowledge the receipt of a copy of the Town's HIPAA policy and training on that policy.
Original Author:Norris, Margaret
Product Create Date:08/27/2003
Last Reviewed on::05/16/2017
Subject:Forms; Insurance--Health; Insurance; Records management--Open records; Records management--Open records--Laws and regulations; Personnel--Fringe benefits--Laws and regulations; Personnel--Fringe benefits; Personnel--Laws and regulations--Federal
Original Document: HIPAA training acknowledgment form.pdfHIPAA training acknowledgment form.pdf

Reference Documents:

Text of Document: HIPAA training acknowledgment form.docHIPAA training acknowledgment form.doc

Town of ___________

As an employee, I hereby acknowledge that I have received and do now possess a complete and current copy of the Town of Centerville’s Health Insurance Portability and Accountability Act (HIPAA) Policy passed by resolution on ___________, 20__. I also acknowledge that I received and participated in training on this policy on ____________, 20__.

I agree without reservation to follow and abide by the policies, procedures, rules and regulations contained therein.

Furthermore, I understand that the Town reserves the right to change any of such rules, regulations, policies, practices, and procedures in whole or in part at any time, with or without notice to employees.

Name of Employee: _____________________________________________________________

Department Name: ______________________________________________________________

Social Security Number: _________________________________________________________

Signature of Employee ___________________________________ Date______________

Signature of Witness _____________________________________ Date______________