Acknowledgement of receipt of Notice of privacy practices

Acknowledgement of receipt of
Notice of privacy practices

You information is safe! The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately.

I have received a copy of the Coast Periodontics & Laser Surgery, Notice of Privacy Practices.

Please Print Name: *

Signature: *

Clear

Date: *

If this Acknowledgement is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative's Name:

Relationship to Patient:

For Program Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement

This resource is provided by the CDA Practice Support Center.
Visit the website at cdacompass.com or call 800.232.7645.
© 2013 California Dental Association