HIPAA privacy notice acknowledgement form
22 reviews

Use our readymade template to create this Google form. Customize it further using our form builder.

Get Acknowledgement using Google Forms

Consent form builder
  • navigate_next Use our prebuilt template to create your HIPAA Privacy Notice Acknowledgement form
  • navigate_next Collect patient details such as name, email, contact number and date of birth
  • navigate_next Specify the acknowledgement details such as healthcare provider name, patient rights, use and disclosure of health information
  • navigate_next Get legally binding signatures from the patient for the acknowledgement

Collect signatures from the patient

Consent form builder
  • navigate_next Embed the form on your website or use the share link to collect responses
  • navigate_next Provide a user friendly, secure and seamless signing experience
  • navigate_next Enable patients to sign and submit the form from any device
  • navigate_next Send a confirmation email with the signed copy of the HIPAA Privacy Notice Acknowledgement
  • navigate_next Allow patients to save progress & complete the acknowledgement form later

Track signed responses in Google Sheets and Drive

1 Email Preferred contact number Date of birth Patient Name Signed PDF
2 johndoe@example.com (555) 123-4567 01-01-1980 John Doe Signed PDF
3 janesmith@email.com (555) 987-6543 02-02-1985 Jane Smith Signed PDF
4 alex.johnson@mail.com (555) 555-1234 03-03-1990 Alex Johnson Signed PDF
5 emily.davis@example.org (555) 456-7890 04-04-1995 Emily Davis Signed PDF
6 michaelb@emailprovider.com (555) 321-0987 05-05-2000 Michael Brown Signed PDF
7 sarah.johnson@example.com (555) 777-8888 06-06-1982 Sarah Johnson Signed PDF
8 david.miller@emailprovider.com (555) 444-3333 07-07-1987 David Miller Signed PDF
9 olivia.wilson@email.com (555) 222-9999 08-08-1992 Olivia Wilson Signed PDF
10 daniel.clark@example.org (555) 888-7777 09-09-1997 Daniel Clark Signed PDF
11 sophia.martinez@mail.com (555) 999-6666 10-10-2002 Sophia Martinez Signed PDF
  • navigate_next Sync the signed HIPAA Privacy Notice Acknowledgement to your Google Drive for record keeping
  • navigate_next Easily track and manage your form responses using the Kanban board
  • navigate_next Automatically receive a copy of the signed HIPAA Privacy Notice Acknowledgement by email
  • navigate_next Sync form responses with signatures to Google Sheets for further analysis
  • navigate_next Notify your team by email when a patient submits the acknowledgement form

These reviews are reproduced without modification from Google Workspace Marketplace.

July 27, 2023

5 stars

I am 100% a fan of this company. We use HIPAA compliant Google Forms and needed a way to collect signatures, the industry standard company is TOO expensive. I started using FormEsign and it worked perfectly. It lacked the ability to provide a pdf copy of the form after signature. This company worked with me help their product evolve into something that could benefit all future clients AND the end user. The team was polite, professional, kind, enthusiastic, and willing to make a change. This earned my loyalty. I will sing their praises. Good work, and thank you!

— Royal Bush

July 23, 2023

5 stars

I am not tech savvy. I chose formesign to help create registration links for clients. Vipid has been great in assisting me. He goes above and beyond. My company now has moved from the stone age to modern age through the ability to use this feature. Of the many features I am impressed with, the ability to update a form without needing to regenerate a link is amazing. I often make mistakes and that ability allows me to fix mistakes without needing to change everything. Thank you!!!

— Sol Evans

October 31, 2023

5 stars

We needed a way to create forms with e-signatures and this app made it very easy. Support is also very quick and always helpful. Cannot recommend enough!

— Chris Henesy

February 16, 2024

1 stars

Does not work

— Myles Sicuro

July 12, 2023

5 stars

It very friendly to used. I love it. For my case multiple signature needed. it's supporting

— Senthil Kumar

November 27, 2023

5 stars

Yeah this is good for all

— luqman khan

July 10, 2023

5 stars

We were looking for a way to have a signature option in our form. Formesign addon allowed us to collect signatures for the acknowledgment and consent forms. It was simple and easy to setup. Very useful addon for google forms.

— Joan S