Acknowledgement of Receipt of HIPAA Policies and Procedures

Click on the hyperlink to obtain a copy:

I have received and reviewed a copy of the dental practice's privacy, security and breach notification policies and procedures.

I understand that I should ask the dental practice's Privacy Official if I have any questions about these policies and procedures.

Patients over 18 yrs old

It is understood that our office will share information regarding your treatment with yourself and doctors. If you would like us to release information regarding your treatment to a loved one, should they call on your behalf, please list their names and relationships below.

Patients under 18 yrs old

It is understood that our office will share information regarding treatment of minors with parents and doctors. If you would like us to release information regarding the patient's treatment to anyone else, should they call on your behalf, please list their names and relationships below.

Online Signature×
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By clicking the accept button below, I agree that the signature I have drawn above will be the electronic representation of my signature for all purposes when I use them on online documents and forms - just the same as a pen-and-paper signature.