Dental History Page 3
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A
M
M
D. D. S., P.A
R I A N
.
c
U R T R Y ,
.
10816 Black Dog Lane, Suite 100, Charlotte NC 28214
Acknowledgement of Receipt Of Notice of Privacy Practices
Available in-office and online at
Name:
_______________________
Address : ___________________________
__________________________
I have received a copy of the Notice of Privacy Practices for the above named practice.
_______________________________
_____________________
Signature
Date
Release of Information Authorization for Family and Friends
Dr. McMurtry’s office is authorized to release protected health information about the above named patient to the entities
named below. The purpose is to inform the patient or others in keeping with the patient’s instructions.
Entity to Receive Information.
Description of information to be released.
Check each person/entity that you approve to receive
Check each that can be given to person/entity on the left in
the same section.
.
information
Spouse
Family billing information
Medical
Parent (provide name)__________________
Family Billing Information
Medical
Other (provide name) __________________________
Financial
_____________________________________________
Medical as follows _____________________
Rights of the Patient.
I understand that I can revoke this authorization at any time and that I have the right to inspect or copy
the protected health information to be disclosed as described in this document by sending a written notification to Dr. McMurtry’s
office. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective
going forward. I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the
recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization
and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient.
_______________________________
_____________________
Signature
Date
For Office Use Only
We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because:
An emergency existed & a signature was not possible at the time.
The individual refused to sign.
A copy was mailed with a request for a signature by return mail.
Unable to communicate with the patient for the following reason: _________________________________________
Other:__________________________________________________________________________________________
Prepared By _________________________________________
Date: _________________
Signature
_________________________________________
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