Notice Of Privacy Practices

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Notice to Patient:

We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgment, if you wish.

I acknowledge that I have received a copy of this office's Notice of Privacy Practices.

Please print your name here:

Signature:

Clear Signature

Date:

DO YOU GIVE US PERMISSION TO DISCUSS ANY OF YOUR DENTAL NEEDS WITH A SPOUSE, CHILD, OR PARENT?

Please print the name of the individual:

A SPOUSE, the

HIPAA Acknowledgment of receipt of the Notice of Privacy practices

This form does not constitute legal advice and covers only federal, not state, law.