I hereby acknowledge that I have received and reviewed a copy of Danville Pediatric Dentistry's HIPAA Notice of Privacy Practices.

 

I understand that Danville Pediatric Dentistry's HIPAA Notice of Privacy Practices may change periodically and that I am entitled to receive a copy of Danville Pediatric Dentistry's revised HIPAA Notice of Privacy Practices upon request.

 

I understand that, if I have questions about Danville Pediatric Dentistry's HIPAA Notice of Privacy Practices, I may contact Monica Mosley.

 

I understand that it is my right to refuse to sign this Acknowledgement should I so choose, and that Danville Pediatric Dentistry will not refuse treatment to me if I refuse to sign this Acknowledgement.

 

I further understand that I may contact the Secretary of the U.S. Department of Health and Human Services should I have concerns regarding Danville Pediatric Dentistry's privacy policies and procedures. For information on how to contact the U.S. Department of Health and Human Services, please ask Monica Mosley, noted above, for assistance.