Home
About Us
Services
Testimonials
Careers
Blog
COVID-19 Questionaire
Patient Forms
Patient Registration Form
Financial Agreement
HIPAA Privacy Form
Medical History
Select Page
HIPAA Privacy Form
Hidden
HIPAA PRIVACY FORM Acknowledgement of Receipt of Notice Of Privacy Practices Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to Document our good faith effort to obtain that acknowledgement. **You may refuse to sign this acknowledgement**
HIPAA PRIVACY FORM
Acknowledgement of Receipt of Notice
Of Privacy Practices
Best Care Dental
Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to Document our good faith effort to obtain that acknowledgement.
**You may refuse to sign this acknowledgement**
I,
Name
*
Hidden
has received a copy/explanation of this office’s Notice of Privacy Practices.
, have received a copy/explanation of this office’s Notice of Privacy Practices.
Signature of Patient and/or Guardian
Date
*
MM slash DD slash YYYY
Relationship to Patient
*
Self
Authorization to Release Information
Purpose: This form is used to obtain authorization to release information regarding you or minor covered under the Privacy Act to people other than yourself.
Full Name
Relationship
Full Name
Relationship