What can we help you find today?

HIPAA Training Acknowledgment Form

Print This PagePrint This Page Send by EmailSend by Email
Reviewed Date: May 16, 2017

Original Author: 
Norris, Margaret
Date of Material: 
Aug 27, 2003

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

HIPAA Training Acknowledgment Form

A form to acknowledge the receipt of a copy of the Town's HIPAA policy and training on that policy.


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______________


About Our Knowledgebase

Information written by MTAS staff was based on the law at the time and/or a specific sets of facts. The laws referenced may have changed and/or the technical advice provided may not be applicable to your city or circumstances. Always consult with your city attorney or an MTAS consultant before taking any action based on information posted to this website.