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
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