HIPPA Form Online

To expedite you next appointment, please fill out the HIPPA form below. You may complete this form online—it will be sent directly to our office—or you may download, print, complete, and bring it with you to your scheduled appointment.

 

  • 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 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 improvement activities
  • 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.

  • This field is for validation purposes and should be left unchanged.