whiterosefamilydental.com - Acknowledgement of Receipt of Notice of Privacy Practice

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I understand that, under the Health Insurance Portability & Accountability Act (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple health care provides who may be involved in that treatment directly and indirectly
- Obtain payment from third-party payers.
- Conduct normal health care operation such as quality assessments and physician’s certifications.
I have received, read, and understood your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to changes it’s Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operation. I also understand that you are not required to agree to my requested restriction, but if you do agree then you are bound to abide by such restrictions.
Patient Name :
Date of Birth:

MonthDayYear
Date
*Written communications: Address to:
If the address provided is not your home address or is not a street address, please provide us with street address for purposes of ensuring payment.

*Oral communications: call:
(Please fill in all that apply)
Home #
Please enter a valid phone number.
Work #
Please enter a valid phone number.
Cell #
Please enter a valid phone number.
*Oral communications: call:
May we leave a message that you need pre-medication?

YesNo
May we leave a message you have a dental appointment?

YesNo
I do not want any reminder messages left at all
(initials)
I do not want a postcard send
(initials)
****OFFICE USE ONLY****

I attempted to obtain the patient’s signature in acknowledgment on the Notice of Privacy Practices but was unable to do so as documented below.
DATE:

MonthDayYear
Date
REASON:
INITIALS:
Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA
Should be Empty:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES