Notice Of Privacy Practices And Dental Materials Fact Sheet

Download a blank fillable Notice Of Privacy Practices And Dental Materials Fact Sheet in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Notice Of Privacy Practices And Dental Materials Fact Sheet with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

NOTICE OF PRIVACY PRACTICES AND DENTAL MATERIALS FACT SHEET
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires that
healthcare providers give each patient a copy of the provider’s Notice of Privacy Practices, and
then make a good-faith effort to obtain an acknowledgement of receipt for the notice. Patients
may refuse to sign for receipt.
By signing this form, I confirm that I have received a copy of the Dental Office’s Notice of
Privacy Practices and a copy of the Dental Materials Fact Sheet.
Patient or Parent/Guardian Printed Name
Patient or Parent/Guardian Signature
Date
Office Use
Written acknowledgement was not obtained because:
□ Patient refused to sign
□ Unable to communicate with patient
□ Emergency situation
□ Other

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go