NOTICE OF PRIVACY PRACTICES-ACKNOWLEDGEMENT

NOTICE OF PRIVACY PRACTICES-ACKNOWLEDGEMENT
Sunshine Dental Care keeps a record of health care services we provide you. You may ask to see and obtain a copy of that record. We will not disclose your record to others unless you direct us to do so, or unless the law authorizes or compels us to do so. You may see your record or get more information by contacting our office at 425-481-8571 or emailing office@sunshinedentalcare.net

Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.

By my signature below I acknowledge that I have received or was offered a copy of this practice's HIPAA Notice of Privacy Practices.
Patient Or Legally Authorized Individual Signature

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Printed Name
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To protect your medical confidentiality we will not discuss details of your treatment with anyone unless authorized by you. If you would like to authorize us to release treatment information and/or leave detailed messages regarding your treatment, please check one:
Spouse / Partner:
Parent / Guardian:
Power Of Attorney:
Other:
With my signature below, I acknowledge and understand that this information will be kept in my medical record and the above parameters will be abided by until revoked by me in writing. It is my responsibility to notify Sunshine Dental Care should I wish to change any of the information listed above.
Signature of Patient / Guardian

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