Notice Of Privacy Practices - Acknowledgement printable pdf download

Notice Of Privacy Practices - Acknowledgement

NOTICE OF PRIVACY PRACTICES -ACKNOWLEDGEMENT

We keep a record of the health care services we provide you. You may ask to see and

copy that record. You may also ask to correct that record. We will not disclose your

record to others unless you direct us to do so or unless the law authorizes or compels us

to do so. You may see your record or get more information about it by contacting Patti

Thomas, Privacy Officer for the office.

Our Notice of Privacy Practices describes in more detail how your health information

may be used and disclosed, and how you can access your information.

By my signature below I acknowledge receipt of the Notice of Privacy Practices.

__________________________________________________________

____________________________________

Patient or legally authorized individual signature

Date

Time

__________________________________________________________

____________________________________

Printed name if signed on behalf of the patient

Relationship

(parent, legal guardian, personal representative)

Do you give permission for your spouse or family member to discuss your treatment or financial

arrangements with the office?

YES ___________________________________ (name permission given to)

(Notation, if any, by staff)

This form will be retained in your dental record.

Notice Of Privacy Practices - Acknowledgement