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HIPAA Privacy Form
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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
