Patient Acknowledgement Of Receipt Of Notice Of Privacy Practices And Consent/limited Authorization & Release Form printable pdf download

Patient Acknowledgement Of Receipt Of Notice Of Privacy Practices And Consent/limited Authorization & Release Form

HIPPA OMNIBUS RULE

Patient Acknowledgement of receipt

Of notice of privacy practices and consent/limited authorization

& release form

You may refuse to sign this acknowledgement & authorization. In refusing We MAY NOT BE ALLOWED TO

PROCESS YOUR INSURANCE CLAIMS.

Please print your name:__________________________________________

The undersigned acknowledges receipt of a copy of the currently effective notice

of privacy practices for this healthcare facility. A copy of this signed, dated

document shall be as effective as the original.

_________ (Initial here) Acknowledge that Holt Family Dentistry corresponds

electronically and /or over the phone with referral doctors with health information.

Please list any other parties who can have access to your health information

(This includes spouse, friend, care taker or family member ie; parent, step parent, child, or grandparent,)

Name:_______________________

Relationship:_______________________

Name:_______________________

Relationship_______________________

I authorize contact from this office to Confirm my Appointment, Treatment,& Billing

Information VIA:

Cell phone confirmation

Home phone confirmation

Work phone confirmation

Email confirmation

Any of the above

In signing this HIPPA patient acknowledgement form, you acknowledge and authorize, that this office may recommend products or

services to promote your improved health. This office may or may not receive third party remuneration from these affiliated

companies. We, under current HIPPA Omnibus rule, provide you this information with your knowledge and consent.

You may revoke this authorization in writing or by updating this form.

____________________________

___________________

Patient Signature

Date

_________________________

Legal representative

Description of Authority

Patient Acknowledgement Of Receipt Of Notice Of Privacy Practices And Consent/limited Authorization & Release Form