Patient Acknowledgement And Consent Form - Anderson Dental Associates printable pdf download

Patient Acknowledgement and Consent Form

Effective April 14, 2003, the new 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 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.

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 other 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.

Please sign this form below to acknowledge that you have either received or reviewed a copy of our Notice

of Privacy Practices and to consent to our disclosures of your information that we deem necessary in order

to provide your with proper treatment.

I acknowledge that I have either received or reviewed a copy of the Notice of Privacy Practices.

I consent to your disclosures of my information, which you deem are necessary in connection with my

treatment. I understand that such disclosures may not be of the type listed above.

____________________________ ____________________________ ____________

Patient Signature

Patient Name (please print)

Date

I am also signing for my minor children: _ _____________________________________________

( please print names)

______________________________________________

( please print names)

Release of Information

I also give consent for my treatment to be discussed with the following individuals: (e.g. spouse, parent,

adult child, caregiver)

___________________________________ ___________________________________

Name

Relationship

___________________________________ ___________________________________

Name

Relationship

___________________________________ ___________________________________

Name

Relationship

___________________________________ ___________________________________

Name

Relationship

Anderson Dental Associates

1431 Howell Branch Road, Winter Park, FL 32789

4076445454

Patient Acknowledgement And Consent Form - Anderson Dental Associates