HIPAA

HIPAA ACKNOWLEDGMENT & CONSENT

Patient First Name

Patient Last Name

Birth Date

Our Notice of Privacy Practice is posted for our patients in our reception area. You have the right to request a copy of this office’s Notice of Privacy Practices at anytime. It can also be found on our website at
www.myhealthysmile.net

By signing this form, you are aware of this office’s Notice of Privacy Practices and consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and dental/healthcare operations.

I will review/print a copy for my records. I have declined to receive a copy of this office’s Notice of Privacy Practices but I am aware I can obtain a copy at any time. I can request a copy at my appointment or print it from this office’s website at www.myhealthysmile.net.

Click on the hyperlink to obtain a copy:

Janis Moriarty DMD's Notice of Privacy Practices

*You May Refuse to Sign This Acknowledgment*

Please list authorized persons with whom we may discuss your Protected Health Information (PHI) in addition to custodial parents and legal guardians:

Name

Phone Number

Relationship to Patient

Name

Phone Number

Relationship to Patient

Form Completion

Signature of Patient, Parent or Guardian

Clear

Clear

Date

If Patient Is A Minor

Form Signed by

Relationship to Patient

Form Completion

If Patient Is A Minor

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