modernendodontics.net-HIPAA-Omnibus

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM
Date

MonthDayYear
Date
The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for
this healthcare facility. A copy of this signed, dated document shall be as effective as the original.
MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR
RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.
Please print name of Patient
Please sign for Patient / Guardian of Patient

Clear
Legal Representative / Guardian
Relationship of Legal Representative / Guardian

Clear
Your comments regarding Acknowledgements or Consents:
HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA:

First Name OnlyProper SurnameOther
PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
(This includes step parents, grandparents and any care takers who can have access to this patient’s
records):
Name:
Relationship:
Name:
Relationship:
I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLINGINFORMATION VIA:

Cell Phone ConfirmationHome Phone ConfirmationWork Phone ConfirmationText Message to my Cell PhoneEmail ConfirmationAny of the Above
I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA:

Cell Phone ConfirmationHome Phone ConfirmationWork Phone ConfirmationText Message to my Cell PhoneEmail ConfirmationAny of the Above
I AUTHORIZE INFORMATION ABOUT MY FINANCIAL ACCOUNT BE CONVEYED VIA:

Cell Phone MessageHome Phone MessageWork Phone MessageText MessageEmailAny of the Above
In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products orservices to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies.We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

Clear
Should be Empty:

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM