cherrycreekpediatricdentistry.com

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES
Today’s Date

MonthDayYear
Date
Patient Name / Your Child’s First & Last Name

First NameLast Name
First & Last Name of ALL siblings
Below is a list of ways our office may contact you. Please check all that apply. Checking a box will give permission to leave as thorough of a message as needed from our dental office.

HomeCellWorkEmailAll the Above
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Patient Authorization for Use and Disclosure of Protected Health Information

I authorize Cherry Creek Pediatric Dentistry to release any information including diagnosis and the records regarding any treatment or examination rendered to my child during the period of such dental care to third party payers and/or other health practitioners. In the event of my absence, the following individuals may bring my child/children to and from their appointments along with have access to medical and financial information.
1. Name {Relationship to patient}
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
2. Name {Relationship to patient}
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
I, {PARENT/GUARDIAN Name}" />{PARENT/GUARDIAN Name} , have been offered a copy of this office’s Notice of Privacy Practices.
Please Print PARENT/GUARDIAN Name
PARENT/GUARDIAN Signature
Should be Empty:

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES