Use our readymade template to create this Google form. Customize it further using our form builder.
Get Acknowledgement using Google Forms
- Use our prebuilt template to create your HIPAA Privacy Notice Acknowledgement form
- Collect patient details such as name, email, contact number and date of birth
- Specify the acknowledgement details such as healthcare provider name, patient rights, use and disclosure of health information
- Get legally binding signatures from the patient for the acknowledgement
Collect signatures from the patient
- Embed the form on your website or use the share link to collect responses
- Provide a user friendly, secure and seamless signing experience
- Enable patients to sign and submit the form from any device
- Send a confirmation email with the signed copy of the HIPAA Privacy Notice Acknowledgement
- Allow patients to save progress & complete the acknowledgement form later
Track signed responses in Google Sheets and Drive
| A | B | C | D | E | |
|---|---|---|---|---|---|
| 1 | 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 |
- Sync the signed HIPAA Privacy Notice Acknowledgement to your Google Drive for record keeping
- Easily track and manage your form responses using the Kanban board
- Automatically receive a copy of the signed HIPAA Privacy Notice Acknowledgement by email
- Sync form responses with signatures to Google Sheets for further analysis
- Notify your team by email when a patient submits the acknowledgement form
These reviews are reproduced without modification from Google Workspace Marketplace.
July 23, 2023
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
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
Does not work
— Myles Sicuro
July 12, 2023
It very friendly to used. I love it. For my case multiple signature needed. it's supporting
— Senthil Kumar
November 27, 2023
Yeah this is good for all
— luqman Khan
July 10, 2023
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