Acknowledgement of Receipt of HIPAA Notice of Privacy Practices

I acknowledge that I have received a copy of this Dental Practice’s HIPAA Notice of Privacy Practices.

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

Patient Name

Date

Release All Information to

Name

Signature of Personal Representative

Authority of Personal Representative to Sign for Patient

Parent Guardian Power of Attorney Other

If Other, please specify

Patient Signature

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