HIPAA Disclosure

Statement of Privacy Practices

Acknowledgement of Privacy Practices

Notice of HIPAA privacy practices and disclosure authorization for Dental Clinic.

Notice of Privacy Practices Summary:

By signing below, you acknowledge that you have been offered or reviewed a copy of our Notice of Privacy Practices. This notice describes how health information about you may be used and disclosed, as well as how you can obtain access to this information.

We are required by applicable federal and state law to maintain the privacy of your health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information (PHI).

1. Patient Identification

Patient Full Legal Name *

Authorized Representative (If Applicable)

Relationship to Patient

2. Digital Signature & Date

Signature of Patient or Authorized Representative*

Sign here using mouse or finger

Date *

256-bit Encrypted & HIPAA Compliant Transmission