Patient Acknowledgement And Consent Form - Green Bay Smiles
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1P
A
C
F
ATIENT
CKNOWLEDGEMENT AND
ONSENT
ORM
Effective April 14, 2003, the federal law known as the Health Insurance Portability and Accountability Act of
1996 (“HIPAA”) requires that this office comply with certain rules regarding the maintenance of the privacy of
your information that we have collected and will collect in the future.
To comply with one of the HIPAA’s requirements, we are giving you a copy of our Notice of Privacy Practices.
This Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our
privacy practices.
Existing Wisconsin Law requires (in addition to our attempt to obtain your written acknowledgement, discussed
above) us to obtain to written consent prior to disclosing any of your information except for our disclosures in
connection with: a defense to a claim challenging our professional competence; a review entity’s functions; a
claim for payment fees; a third party payer’s examination of our records; a court order as part of a criminal
investigation; an identification of a dead body; a licensure investigation; or child abuse/neglect investigation.
From time to time it may be necessary for us to make disclosures of your information in connection with your
treatment. For example, we may make a referral to or consult with another dentist or health care professional,
provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection
with providing or coordinating your treatment.
P
A
C
ATIENT
CKNOWLEDGEMENT AND
ONSENT
P
N
LEASE SIGN THIS FORM BELOW TO ACKNOWLEDGE THAT YOU HAVE TODAY RECEIVED A COPY OF OUR
OTICE OF
P
P
RIVACY
RACTICES AND THAT YOU CONSENT TO OUR DISCLOSURES OF YOUR INFORMATION THAT WE DEEM
.
NECESSARY IN ORDER TO PROVIDE YOU WITH PROPER TREATMENT
Signature___________________________________________________
Print Name_________________________________________________ Date_________________________
A
R
I
UTHORIZATION TO
ELEASE
NFORMATION
I, ______________________________________, authorize the following person(s) to have access to
information covered under the Privacy Practice regarding myself.
_______________________________________________
____________________________________
(Please Print Name)
Relationship
_______________________________________________
____________________________________
(Please Print Name)
Relationship
_______________________________________________
____________________________________
(Please Print Name)
Relationship
F
O
U
O
OR
FFICE
SE
NLY
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
o
An emergency situation prevented us from obtaining the acknowledgement
o
Communication barriers prohibited obtaining the acknowledgement
o
Other (please specify)__________________________________________________________________________________________________________
o
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