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 Submit Form Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.
