Acknowledgement of Receipt of HIPAA

SURF'S UP PEDIATRIC DENTISTRY
ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES
Please list each patient(s) first name: *

Patient(s) First NamePatient(s) Last Name
YOU MAY REFUSE TO SIGN THIS AGREEMENT.

I give consent for the Use and Disclosure of Health Information of myself and/or my dependent(s) for the purpose of the Treatment, Payment or Communication between other healthcare professionals. I understand that I have the right to review a copy of this office's Notice of Privacy Practices prior to signing the condensed form.
Signature of Parent/Guardian Date

Clear
Name of Parent/Guardian*
Relationship to Patient(s)*
FOR OFFICE USE ONLY
We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual Refused to SignCommunication barriers prohibited obtaining the acknowledgementAn emergency situation prevented us from obtaining acknowledgmentOther(Please Specify):
Should be Empty:

SURF'S UP PEDIATRIC DENTISTRY