Notice Of Privacy Practices And Dental Materials Fact Sheet
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1NOTICE OF PRIVACY PRACTICES AND DENTAL MATERIALS FACT SHEET
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires that
healthcare providers give each patient a copy of the provider’s Notice of Privacy Practices, and
then make a good-faith effort to obtain an acknowledgement of receipt for the notice. Patients
may refuse to sign for receipt.
By signing this form, I confirm that I have received a copy of the Dental Office’s Notice of
Privacy Practices and a copy of the Dental Materials Fact Sheet.
Patient or Parent/Guardian Printed Name
Patient or Parent/Guardian Signature
Date
Office Use
Written acknowledgement was not obtained because:
□ Patient refused to sign
□ Unable to communicate with patient
□ Emergency situation
□ Other
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