statonfamilydentistry.com - Acknowledgement Form

Notice of Privacy Practices Acknowledgement

Staton Family Dentistry
Trevor Staton DMD

Ronnie Dyer DMD & Michael Worthy DMD
48 Haralson Place, Suite 4
Blairsville, GA 30512
706-745-9621

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights of 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 multiple healthcare providers who may be involved in my treatment plan—directly or indirectly
- Obtain payment from third-party payers
- Conduct normal healthcare operations such as quality assessments and physician certifications
I acknowledge that I have received 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 change its 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 operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
Patient Name:
Relationship to Patient:
Signature:

Clear
Date:

MonthDayYear
Date
Office Use ONLY:

I attempted to obtain the patient’s signature in acknowledgement of receipt of Notice of Privacy Practices, but was unable to do so as documented below:

Date: _________________

Initials: ________

Reason: ________________________________________
Should be Empty:

Notice of Privacy Practices Acknowledgement