ACKNOWLEDGEMENT OF PRIVACY PRACTICES
My signature confirms that I have been informed of my rights to privacy regarding my
protected health information, under the Health Insurance Portability & Accountability Act
of 1996 (HIPAA). I understand that this information can and will be used to:
Provide and coordinate my treatment among a number of health care providers
who may be involved in that treatment directly and indirectly
- Obtain payment from third-party payers for my health care services
Conduct normal health care operations such as quality assessment and
I have been informed of my dental provider’s Notice of Privacy Practices containing a more
complete description of the uses and disclosures of my protected health information. I
have been given the right to review and receive a copy of such Notice of Privacy Practices.
I understand that my dental provider has the right to change the Notice of Privacy Practices
and that I may contact this office at the address above to obtain a current copy of the
Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is
used or disclosed to carry out treatment, payment or health care operations and I
understand that you are not required to agree to my requested restrictions, but if you do
agree then you are bound to abide by such restrictions.
For Office Use Only:
We were unable to obtain the patient’s written acknowledgement of our Notice of Privacy Practices due to the
20011 Ballinger Way NE, Suite B100 – Shoreline, WA 98155
Phone: (206) 946-6471 – Fax: (206) 946-6473