HIPPA Acknowledgement Form

Acknowledgement of Receipt of Notice of Privacy Practices

*You May Refuse to Sign this Acknowledgement*
My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:
Provide and coordinate my treatment among a number of healthcare providers who may be involved in that treatment directly and indirectlyObtain payment from third-party payers for my health care services (insurance companies)Conduct normal health care operations such as quality assessment and improvement activities I have been informed of my dental provider’s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information.
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 healthcare operations and I understand that 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:
Date:

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Signature:

Clear
Relationship to Patient:
Dependent family members also covered by this acknowledgement:
AUTHORIZATION TO RELEASE INFORMATION TO OTHER
Many of our patients allow family members or others close to them to call and request information regarding their condition and/or treatment. Under the requirements for H.I.P.P.A. we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your dental condition and/or dental treatment disclosed to someone else indicate below. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.
You May Disclose My Information To The FollowingDo Not Disclose My Information to Anyone But Me
1.
Relationship to Patient:
Date:

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Date
2.
Relationship to Patient:
Date:

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Should be Empty:

Acknowledgement of Receipt of Notice of Privacy Practices

AUTHORIZATION TO RELEASE INFORMATION TO OTHER