To help keep our patients safe and healthy during the COVID-19 pandemic, Hymas Family Dental will be available for you Emergency Dental Needs.
Call our office if you are in pain or have an infection that needs medical attention right away. Dr Hymas is here to keep you out of the Emergency Room.
Hymas Family Dental | HIPAA Release | Dentist in Spokane Valley
509-922-1360Request an Appointment

420 N Evergreen Rd # 400, Spokane Valley, WA 99216

Patient Forms
Make A Payment

HIPAA Release

Date:
 
I have read and been offered a hard copy or an electronic copy of theHIPAA Notice of Privacy Practicesfor Hymas Family Dental. I understand that I am entitled to receive a hard copy of the Notice if I ask for it, even if I have already agreed to receive only an electronic copy.
 
Date:
Relationship to patient: Self Parent Guardian Legal Representative
     
If applicable:
Patient's Guardian or Representative's name:
Phone:
Representative's relationship to patient:
Representative's address:
 

Permission To Discuss Treatment Or Billing Information

 
I give permission to discuss my treatment and or billing information with:
 
Name
Relationship to patient
Your request has been sent -- we will be in contact with you shortly.
There was an error! Please phone our office.
Request an Appointment