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

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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.
 
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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

 
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