Hymas Family Dental | HIPPA Acknowledgement

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 | HIPPA Acknowledgement | Dentist in Spokane, WA

509-922-1360 Request an Appointment

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

Patient Forms

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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. 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

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