DFW Implant Team: HIPPA PRIVACY STATEMENT & ACKNOWLEDGEMENT

HIPAA NOTICE OF PRIVACY PRACTICES

The HIPAA Notice of Privacy Practices describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your health information is important to us.
Patient Name

First NameLast Name
Birth Date

MonthDayYear
ACKNOWLEDGEMENT OF RECEIPT

**You may refuse to sign this acknowledgement.**
I   First Name*   Last Name* , have been offered a copy of this office’s Notice of Privacy Practices.



I   *   authorize you to leave messages on my answering machine or voice mail regarding appointments.

I   *   authorize you to use my radiographs and/ or pictures for use in professional presentations for educational purposes. Your identity will not be disclosed.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please verify that you are human
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HIPAA NOTICE OF PRIVACY PRACTICES