Acknowledgements of Privacy Practices

Patient Consent Form

Please correct the errors described below.

My signature confirms that I have been informed of my rights to privacy regarding my protected information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:

  • Provide and coordinate my treatment among a number. of health care providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from a third-party payer(s) for my health care services.
  • Conduct normal health care operations such as quality assessment and improvement activities.

I have been informed of my dental provider’s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notices of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations, and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.


Many of our patients allow family members or others close to them to call and request information regarding their condition and/or treatment. Under the requirements for H.I.P.A.A., we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your dental condition and/or dental treatment disclosed to someone else, indicate below. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent

My information may be disclosed to the following:

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