Patient Privacy

dinka dental

Patient Acknowledgement of Receipt of Notice of Privacy Practices

Please complete form below prior to your first appointment at Dinka Dental. Question? Please contact us.

Patient Acknowledgement of Receipt of Notice of Privacy Practices

I, ______________________________, hereby acknowledge that I have reviewed and received a copy of this office's Notice of Privacy Practices explaining:(Required)

How this office will use and disclose my protected health information.
My privacy rights with regard to my protected health information.
This office's obligations concerning the use and disclosure of my protected health information.

I understand that the Notice of Privacy Practices may be revised from time to time and that I am entitled to receive a copy of any revised Notice of Privacy Practices upon request.

I also understand that if I have any questions or complaints, I may contact:(Required)

You may also contact the Secretary of the U.S. Department of Health and Human Services with any concerns regarding our privacy and security policies and procedures. Please contact our office for information on how to contact the U.S. Department of Health and Human Services.

Today's Date(Required)

Typed Signature(Required)

Relationship to Patient(Required)

Patient Acknowledgement of Receipt of Notice of Privacy Practices

Patient Acknowledgement of Receipt of Notice of Privacy Practices

Patient Reviews & Testimonials

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