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

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Acknowledgement of Receipt of HIPAA Notice of Privacy Practices



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:





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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