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:

• Provide and coordinate my treatment among the number of healthcare providers who may be involved in that treatment directly and indirectly
  
  
• Obtain payment from third-party payers for my health care services
  
  
• Conduct normal healthcare operations such as quality assessment and improvement activities

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.

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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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