Acknowledgement of Privacy Practices

Name *
Acknowledgement *
My signatures confirms that I have been informed of my rights to privacy regarding my protected health information under that 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 heath care providers who may be involved in that treatment directly and indirectly Obtain payment from third-arty payers for my health care services Conduct normal health care operations such as quality assessment and improvement activities. I have been informed of my dental provider’s Notice of Privacy Policy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and received a copy of such Notice of Privacy Policy Practices. I understand that my dental provider has the right to change the Notice of Privacy Policy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Policy 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 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.
Date *
We were unable to obtain the patient's written acknowledgement of our Notice of Privacy Practices due to the following reason: