Privacy Practice Form

My Signature confirms that I have been informed of my rights to privacy regarding my protected health information under the Health Insurance Portability and Accountability Act 1996 (HIPAA). I understand that this information can and will be used to:

  • Provide and coordinate my treatment among a number of health care providers who may be involved in the treatment directly and indirectly.
  • Obtain payment from third-party 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 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 receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy 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 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.


For Office Use Only

We are unable to obtain the patient's written acknowledgment of our Notice of Privacy Practices due to:

The patient refused to signCommunication barriersEmergency situationOther