Privacy Practices Acknowledgement

Privacy Practices Acknowledgement for High Sierra Dental Care Patient Name*

First NameLast Name

Note: All the documents mentioned on this form are provided to you during your fist dental visit and or will be emailed separately to you. I. Authorization to Release Medical, Dental, and Financial Information The only individual we will discuss any of your dental information with is the person you indicated in the box below. If you leave it blank we will not discuss your information with any one what so ever. I grant my permission to (write the name of the person you give us permission to in the box) or ("write I do not give permission to anyone in the box below) to discuss all financial and treatment concerns regarding my dental information. *

What is the persons relationship to you? (describe the relationship in the box)

I request that any and all requests for information and or transfer or records MUST have my written approval, indicated by my signature on a written document with instructions as to what information and where to send it.*

YesNo

Patient Signatures/Legal Guardian*

II. Office Policy About My Account or Dental Treatment Release of Information I understand that no information will be released to any individual or office, without first receiving a written and signed medical release form from me. Patient Signatures/Legal Guardian*

III. Cancellation Fee I am aware that I may be subjected to a cancellation fee for not providing 24 hour advance notice. We require a minimum of 24 hours for any changes of appointments. The fee is $50.00 per One-hour increments. Patient Signatures/Legal Guardian*

VI. Patient Acknowledgment of Receipt of Dental Material Fact SheetI acknowledge that I have receiveda copy of the Dental Materials Fact Sheet dated.These were emailed to you and do not have any patient private information.Patient Signatures/Legal Guardian*

V. I have received a copy of this office’s Notice of Privacy Practices.Patient Signatures/Legal Guardian*

Date*

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Communications barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Privacy Practices Acknowledgement

For Office Use Only