Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

**You May Refuse to Sign This Acknowledgement**

I, have received a copy of the Lyssa A Reed D.D.S. INC. 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.

Name / Signature

Date

If this Acknowledgement is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative's Name

Relationship to Patient

For Program Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please Specify)

Consent Form For Use or Disclosure of Patient Health Information

I authorize Lyssa A. Reed, D.D.S, INC. to use or disclose to

the health information of

for the purpose of

I understand the receiving party may not further disclose this health information without first obtaining a new written authorization from me. I understand this information may be cancelled or modified at any time upon provision of a written notice to this dental practice. I understand that I may refuse to sign this authorization; and that my refusal to sign in no way affects my treatment, payment, enrollment in a health plan, or eligibility benefits. I understand I may have a copy of this authorization.

The health information to be used or disclosed is limited to the following: (you may note dates, procedures, or use other description)

This authorization is valid until:

Signature

Name

Date Signed

Signed by

Patient

Parent/Legal Guardian

Personal Representative of the Patient

Describe the legal authority that permits the representation.

Your information will be encrypted.