HIPAA Acknowledgement Acknowledgement of Receipt of HIPAA Notice of Privacy Practices Patient's First Name Patient's Last Name Birthdate: I have read and been offered a hard copy or an electronic copy of the HIPAA Notice of Privacy Practices for 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. Relationship to Patient: Self Parent Guardian Legal Representative Other (specify) If Applicable: Guardian's First Name Guardian's Last Name Home Phone Address Representative's Relationship to patient: Permission To Discuss Treatment Or Billing Information I give permission to discuss my treatment and or billing information with: SIGNED CONSENT Typed Name/Signature Relationship to Patient Date By clicking here you agree to the above mentioned consent statement Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.
