PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES & CONSENT FORM
Notice of Privacy Practices: Effective 4/14/03, the new federal law, Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected in the past and will collect in the future.
- To comply with one of HIPAA’s requirements, we are giving you a copy of our Notice of Privacy Practices.This Notice contains the information that HIPAA requires us to disclose regarding our privacy practices. Existing MI Law requires us to attempt to obtain your signature acknowledging you have received the Notice discussed above.
- Existing MI Law also requires us to obtain your written consent prior to disclosing any of your information.
Purpose of Consent: From time to time it may be necessary for us to make disclosures of your information in connection with your treatment or payment. For example, we may make a referral to or consult with another dentist or other healthcare professional, use a dental laboratory, communicate with insurer or otherwise make disclosures of your information to provide or coordinate your treatment as outlined in our Notice of Privacy Practices.