NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

In the event that you may want a family member or friend to discuss your dental treatment with our office, we must have permission/consent in writing from you to do so. Please select option “A”, and list any person you give Valley Creek Dental Care permission/consent to discuss your information such as xrays, treatment, account information, etc. If you do not wish to give consent to any person, check option “B” below, sign and date the bottom portion of this form. You MUST choose one option. ***PLEASE NOTE: In the case of a minor, we will discuss dental treatment with either parent or guardian. *
NAME
DATE OF BIRTH
NAME
DATE OF BIRTH
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); to obtain payment from the third-party payers (e.g. my insurance company); and for day-to-day healthcare operations of your practice. I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); to obtain payment from the third-party payers (e.g. my insurance company); and for day-to-day healthcare operations of your practice. I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occured prior to the date I revoke this consent is not affected.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occured prior to the date I revoke this consent is not affected.
DATE