Patient Registration Form - Dentistry Page 3

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NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I, ____________________________________, understand that under the Health Insurance Portability &
Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health
information. I understand that this information can and will be used to:
*Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who
may be involved in that treatment directly and indirectly.
*Obtain payment from third-party payers.
*Conduct normal healthcare operations such as quality assessments and physician certifications.
I have received, read and understand your Notice of Privacy Practices containing a more complete
description of the uses and disclosures of my health information. I understand that I may request in
writing that you restrict how my private information is used or disclosed to carry out treatment, payment
or health care operations. I also understand you are not required to agree to my requested restrictions.
Patient’s Name or Patient Representative: ___________________________________________(Printed)
__________________________________________ (Signature) on _________________________(Date)

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