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  • 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.

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

  • For Program Use Only


  • 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

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