Acknowledgement Of Receipt Of Privacy Practices And Consent For Use And Disclosure Of Health Information Form printable pdf download

Acknowledgement Of Receipt Of Privacy Practices And Consent For Use And Disclosure Of Health Information Form

Dr. E gg P ediatric D entistry

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES AND CONSENT

FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Notice of Private Practices: You have the right to read our Privacy Practices before you decide whether or

not to sign this consent. A copy of our Notice and/or this consent is available upon request. Our Notice

provides a description of our treatment, payment activities and healthcare operations, of the uses and

disclosures we make of your protected health information.

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected

health information to carry out treatment, payment activities, and healthcare operations.

I have been shown a copy of this office’s Notice of Privacy Practices and have had full opportunity to read

and consider its contents. I understand that by signing this consent form, I am giving my consent to your

use and disclosure of my protected health information to carry out treatment, payment activities and

health care operations.

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

Patients Name: ______________________________________________________________

Parent/Legal Guardian Name: ___________________________________________________

Signature: __________________________________________ Date: __________________

Relationship to Patient: _______________________________________________________

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For office 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

▫ Communication barriers prohibited obtaining the acknowledgement

▫ Other (please specify) _________________________________________________________

Acknowledgement Of Receipt Of Privacy Practices And Consent For Use And Disclosure Of Health Information Form