HIPAA Acknowledgment

We realize that there are often circumstances in which you cannot control and we will try to work with you, so please let us know the reason for cancellation.

• 24-hour Cancellation/No Show policy – We request 24-hour cancellation notice in order to give other patients the opportunity to receive treatment. Please give us as much notice as possible when canceling an appointment.
  • You will be charged $75 for a cancelled scheduled appointment when notice given is less than 24 hours before appointment time or for failing to attend your scheduled appointment without 24-hour cancellation notification.
  • Exceptions will be made for illness and inclement weather.

Late Arrival policy – In the event you arrive late for your appointment, your treatment will end at its scheduled time in order not to keep the next person waiting. Remaining services will be scheduled at another time.

As required by the HIPAA Privacy Regulations, all patients (or patient’s personal representative) who receive health care services on or after April 14, 2003 must: 

• Receive and review the attached “Notice of Privacy Practices”, and
• Review and sign the “Acknowledgment Form” for our records.

I have been presented with a copy of this provider’s Notice of Privacy Policies, detailing how my information may be used and disclosed as permitted under federal and state law. I understand the contents of the Notice, and I request the following restriction(s) concerning my personal medical information.

Further, I permit a copy of this authorization to be used in place of the original. Please note that the attached Notice of Privacy Policies is not a consent form that must be read in full by the patient and signed before treatment can be provided; rather, the Notice provides each patient with a summary description of: 

• How our office will use and disclose their medical information for legitimate business purposes,and
• How each patient can exercise their rights regarding this medical information.

If you have any questions about this notice, please call our office at (303) 978-1104 and ask for our HIPAA compliance administrator.

I authorize Southwest Pediatric Dentistry & Orthodontics, PC to share my Protected Health Information to be disclosed for purposes of communicating results, findings, treatment decisions and financial issues to the family members and others listed below. This will serve as my electronic signature for the Consent for Disclosure Form (If a power of attorney, please provide a copy of the POA).

By signing below, I hereby acknowledge that I have read, understood, and agree to abide by our Appointment Policy as described above and that I understand I may obtain a copy of our Notice of Privacy Practices at our office.