Acknowledgement Of Receipt Of Notice Of Privacy Practices

More Smiles of Beverly welcomes you. To help us meet all your healthcare needs, please fill out this form completely. If you have any questions or need assistance, please ask us and we will be happy to help.

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information, I understand that this information can and will be used to:

1. Conduct, plan and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly.

2. Obtain payment from third party payers.

3. Conduct normal health care operations such as quality assessments and physician certifications.

I have received, read and understand your Notice Of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice 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 operation. I also understand that you are not required to agree to my requested restriction, but if you agree then you are bound to abide by such restrictions.

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 / Signature:

Relationship to Patient

Date:

Request for Confidential Communications

Patient Name:

Date:

Address:

If the address provided above Is not your home address or it is not a street address, please provide us with a street for purposes of ensuring payment.

Home #:

May we leave a message?

Yes No

Work #:

May we leave a message?

Yes No

Cell #:

May we leave a message?

Yes No

Email:

May we leave a message?

Yes No

May we send an appointment reminder text message?

Yes No

May we leave a message that you need pre-medication?

Yes No

May we leave a message that you have a dental appointment?

Yes No

I do not want a reminder left at all (Initials)

I do not want a postcard sent (Initials)

I understand that the office may charge me should I fail to keep my appolntment*oral communication

FOR OFFICE USE ONLY

I attempted to obtain the patient's signature in acknowledgement on the Notice of Privacy Practices but was unable to do so as documented below.

Date field

Reason

Initials

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