Patient Acknowledgement of Receipt of Notice of Privacy Practices and Consent/Limited Authorization and Release Form

You may refuse to sign this acknowledgment and authorization. In refusing we may not be allowed to process your insurance claims.

I hereby acknowledge that I have been given the right to review the office's Notice of Privacy (HIPAA). A copy of this notice can be viewed here.

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for Frankenmuth Family Dental/Hemlock Family Dental. A copy of this signed, dated documents shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITIES IN THE FUTURE.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Agreement to Receive Electronic Communication

I, the undersigned, do agree that Frankenmuth Family Dental/Hemlock Family Dental may communicate with me electronically at the email address and/or mobile phone number listed below.

I can withdraw my consent to electronic communication at any time by contacting:

Frankenmuth Family Dental

(989) 652-6196

frankenmuth@frankenmuthfamilydental.com

Hemlock Family Dental

(989) 642-2750

hemlock@frankenmuthfamilydental.com

I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I further agree that I am responsible for providing the dental practice any updates to my email address and/or mobile phone number.