Hipaa Privacy Rule Receipt Of Notice Of Privacy Practices Written Acknowledgement Form printable pdf download

HIPAA Privacy Rule Receipt of Notice of Privacy Practices Written Acknowledgement

Form

Acknowledgement of receipt of Information Practices Notice (§164.520(a))

I understand that as part of my health care, Ukiah Family Dentistry originates and maintains health records

describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for

future care or treatment. I acknowledge that I have been provided with and understand that Ukiah Family Dentistry

Notice of Privacy Practices provides a complete description of the uses and disclosures of my health

information. I understand that:

I have the right to review Ukiah Family Dentistry Notice of Privacy Practices prior to signing this

acknowledgement;

that Ukiah Family Dentistry reserves the right to change their Notice of Privacy Practices and prior to

implementation of this, will mail a copy of any revised notice to the address I've provided if requested.

HIPAA Privacy Rule of Patient Authorization Agreement

Authorization for the Disclosure of Protected Health Information

for Treatment, Payment, or Healthcare Operations (§164.508(a))

I understand that as part of my health care, Ukiah Family Dentistry, originates and maintains health records

describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for

future care or treatment. I understand that this information serves as:

a basis for planning my care and treatment;

a means of communication among the health professionals who may contribute to my health care;

a source of information for applying my diagnosis and surgical information to my bill;

a means by which a third-party payer can verify that services billed were actually provided;

a tool for routine health care operations such as assessing quality and reviewing the competence

of health care professionals.

I understand that as part of my care and treatment it may be necessary to provide my Protected Health

Information to another covered entity.

Privacy Rule of Patient Consent Agreement

Consent to the Use and Disclosure of Protected Health Information

for Treatment, Payment, or Healthcare Operations (§164.506(a))

I understand that:

I have the right to object to the use of my health information for directory purposes;

I have the right to request restrictions as to how my protected health information may be used or

disclosed to carry out treatment, payment, or healthcare operations and that Ukiah Family

Dentistry, is not required by law to agree to the restrictions requested.

I may revoke this consent in writing at any time, except to the extent that Ukiah Family Dentistry,

has already taken action in reliance thereon.

By law, we are unable to submit claims to payers under assignment of benefits without your

signature. You will however be able to restrict disclosers to your insurance carrier for services for

which you wish to pay “out of pocket” under the new Omnibus Rule. We will not condition

treatment on you signing an authorization / acknowledgement, but we may be forced to decline

you as a new patient or discontinue you as an active patient if you choose not to sign.

I agree to all of the above Office Procedures of Ukiah Family Dentistry, and give my authorization to all of the

above procedures.

Signature of Patient/Guardian: __________________________________Date:___________________

Hipaa Privacy Rule Receipt Of Notice Of Privacy Practices Written Acknowledgement Form