Acknowledgement of Receipt of Statement of Privacy Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Kurt E. Peterson. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Kurt E. Peterson reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

ADDITIONAL DISCLOSURE AUTHORIZATION

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is “NO”. Without indicating “YES” in answer to the each individual question, personal protected (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

Spouse only:

Yes No

Any Member of my immediate family: (Spouse, Children, Children’s Spouses)

Yes No

Any Member of my extended family: (Parents, Grandchildren)

Yes No

Other:

Yes No

If yes, please specify:

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.

Name of patient:

Patient’s personal representative:

Representative’s Telephone Number:

Date:

OFFICE USE ONLY BELOW THIS LINE

Acknowledgement Not Obtained

Provided Prior to Treatment?

Yes No

Date Statement Provided:

Reason for not obtaining patient signature:

Needed more time to review Statement Wanted to consult another person before signing Physically unable to sign No reason offered Other:

If Other is selected, please specify:

Kurt E. Peterson, DDS
1604 W. Riverside Avenue * Spokane, Washington * 99201 * 509-747-2183

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