Patient Acknowledgement And Consent Form printable pdf download

Patient Acknowledgement and Consent Form

McAdoo Dental Office

18424 West McNicholes Rd.

Detroit, Michigan 48219

(313) 537-3800

Effective April 14, 2003. The new federal law known as the Health Insurance Portability and Accountability Act of

1996 (“HIPPA”) requires that this office comply with certain rules regarding the maintenance of the privacy of your

information that we have collected and will collect in the future.

To comply with one of HIPAA’s requirements, we are giving you a copy of our Notice of Privacy Practices. This

Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy

practices. Existing Michigan Law requires (in addition to our attempt to obtain your written acknowledgement,

discussed above) us to first obtain your written consent prior to disclosing any of your information except for our

disclosures in connection with: a defense to a claim challenging our professional competence; a review entity’s

functions; a claim for payment of fees; a third party payer’s examination of our records; a court order as part of a

criminal investigation; an identification of a dead body; a licensure investigation; or a child abuse/neglect

investigation.

From time to time it may be necessary for us to make disclosures of your information in connection with your

treatment. For example, we may make a referral to or consult with another dentist or other health care

professional, provide a specimen to a laboratory for testing or otherwise make disclosures of your information in

connection with providing or coordinating your treatment.

Patient Acknowledgement

Please sign this form below under the heading “Patient Acknowledgement” to acknowledge that you have today

received a copy of our Notice of Privacy Practices.

Patient Signatures______________________________________________________ Date____________________

Patient Name __________________________________________________________________________________

(Please print)

For office use only

Patient Refused to Sign

The following circumstances prohibited the patient from signing the Acknowledgement_______________________

______________________________________________________________________________________________

An emergency situation prevented the patient from signing the Acknowledgement

Office Personnel (Signature)_________________________________________________ Date__________________

Office Personnel (print name)______________________________________________________________________

Patient Consent

Please sign this form below under the heading “Patient Consent” to consent to our disclosures of your information

that we deem necessary in order to provide you with proper treatment.

I consent to your disclosures of my information, which you deem are necessary, in connection with my treatment. I

understand that such disclosures may not be of the type listed above.

Patient Signature ________________________________________________Date___________________________

Patient Name__________________________________________________________________________________

(Please print)

Patient Acknowledgement And Consent Form