Acknowledgement Of Receipt Of Privacy Practices And Consent For Use And Disclosure Of Health Information Form

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Dr.   E gg   P ediatric   D entistry  
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES AND CONSENT
FOR USE AND DISCLOSURE OF HEALTH INFORMATION
Notice of Private Practices: You have the right to read our Privacy Practices before you decide whether or
not to sign this consent. A copy of our Notice and/or this consent is available upon request. Our Notice
provides a description of our treatment, payment activities and healthcare operations, of the uses and
disclosures we make of your protected health information.
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected
health information to carry out treatment, payment activities, and healthcare operations.
I have been shown a copy of this office’s Notice of Privacy Practices and have had full opportunity to read
and consider its contents. I understand that by signing this consent form, I am giving my consent to your
use and disclosure of my protected health information to carry out treatment, payment activities and
health care operations.
If this consent is signed by a personal representative on behalf of the patient, complete the following:
Patients Name: ______________________________________________________________
Parent/Legal Guardian Name: ___________________________________________________
Signature: __________________________________________ Date: __________________
Relationship to Patient: _______________________________________________________
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For office use only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement
could not be obtained because:
▫ Individual refused to sign
▫ Communication barriers prohibited obtaining the acknowledgement
▫ Other (please specify) _________________________________________________________

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