Medical History Form - Fresh Dental Page 2
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1
2NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL/PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
SUMMARY:
By law we are required to provide you with our Notice of Privacy Practices (NPP). This notice describes how
your medical information may be used and disclosed by us. It also tells you how you can obtain access to this
information.
As a patient you have the following rights:
1. The right to inspect and copy your information;
2. The right to request corrections to your information;
3. The right to request that your information be restricted;
4. The right to request confidential communications;
5. The right to report of disclosures of your information; and
6. The right to a paper copy of this Notice.
We want to assure you that your medical/protected health information is secure with us. This Notice of Privacy
Practice contains information about how we will insure that your information remains private.
Please list all telephone numbers where we may contact you:
1.__________________________2. ____________________________3. ______________________________
4. _________________________5. ____________________________6. ______________________________
PLEASE LIST THE NAMES OF ALL PEOPLE (e.g. SPOUSE, PARENTS, GRANDPARENTS, ETC...) YOU AUTHORIZE
US TO RELEASE YOUR HEALTH INFORMATION TO, INCLUDING COPIES OF YOUR RECORDS IF NEEDED:
Name ___________________________________________Relationship _______________________________
Name ___________________________________________Relationship _______________________________
Name ___________________________________________Relationship _______________________________
Name ___________________________________________Relationship _______________________________
Acknowledgement of Notice of Privacy Practice
I hereby acknowledge that I have reviewed this practice’s Notice of Privacy Practice. I further understand
that the practice will offer me updated to this Notice of Privacy Practice. Should it be amended, modified or
changed in any way I will receive a copy.
Printed Name of Patient
Signature of Patient/Parent/Guardian
FOR OFFICE USE ONLY
qPatient refused to sign
qPatient was unable to sign because: _________________________
Date: _______________Signature:___________________________
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