HIPAA Privacy Practices Acknowledgment Form

Patient Acknowledgment of Receipt of Notice of Privacy Practices

I, _________________________________ (print name), acknowledge that I have received a copy of [Practice Name]'s Notice of Privacy Practices.

Understanding of Rights

I understand that under the Health Insurance Portability and Accountability Act (HIPAA), I have certain rights regarding my protected health information, including:

• The right to review and receive copies of my dental records
• The right to request restrictions on how my health information is used
• The right to request confidential communications
• The right to amend my health information
• The right to receive an accounting of disclosures of my health information

Authorization for Information Release

I authorize [Practice Name] to release my endodontic and healthcare information to:

1. Other healthcare providers for the purpose of treatment
2. Insurance companies for payment purposes
3. Third parties for healthcare operations

Emergency Contact Authorization

I authorize [Practice Name] to share my relevant health information with:

Name: _______________________________ Relationship: _________________________ Phone: ______________________________

Signature

Patient/Guardian Signature: _____________________________ Date: ________________

For Office Use Only

We attempted to obtain written acknowledgment but could not because:

□ Individual refused to sign □ Communication barrier prohibited obtaining acknowledgment □ Emergency situation prevented obtaining acknowledgment □ Other (specify): ________________________________

Staff Signature: ___________________________ Date: ________________