Acknowledgement of Receipt of Privacy Practices

In compliance with the federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to provide you with a copy of our Notice of Privacy Practices (available on our website and in-person). We are also required to make a good-faith effort to obtain an acknowledgement from you that you have received the Notice; however, you may refuse to sign this acknowledgement. By signing below, you acknowledge that you have received a copy of our notice of privacy practices:

By signing below, you acknowledge that you have received a copy of our 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.

Authorization to Disclose Information for Permitted Uses

From time to time it may be necessary for us to make disclosures of your information in connection with treatment. For example, we may make a referral to or consult with another dentist or other health care professional, provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating of your treatment.

By signing below, you consent to our disclosures of your information that we deem necessary in order to provide you with proper treatment, understanding that such disclosures may not be of the type listed above.

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.

I also give consent for my treatment to be discussed with the following individuals (e.g. spouse, parent, adult child, caregiver):

I give permission to leave messages (and/or text messages) that may or may not be private in nature on my:

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but were unable to do so because:

• Individual refused to sign Other (please specify).
• Communication barriers prevented us from obtaining acknowledgment.
• An emergency situation prevented us from obtaining acknowledgment.