Craig C. Pettey DDS, Inc.
10551 Mills Road
Houston, Texas 77070
281-469-7469

Acknowledgement of Privacy Practices


My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:

I have been informed of my dental provider's Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand the my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Patient Name:

Signature:

Relationship of Patient:

____________________________

____________________________

____________________________

Date: _____________
Dependent family members also covered by this acknowledgement:
_________________________________________________________________________________

_________________________________________________________________________________

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For Office Use Only:

We were unable to obtain the patient' written acknowledgement of our Notice of Privacy Practices due to the following reason:

[ ] The patient refused to sign
[ ] Communication barriers
[ ]Emergency situation
[ ]Other

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