HIPAA-Consent Form for Patients

(Name of practice)

SAMPLE FORM:

Acknowledgment of Receipt of Notice of Privacy Policies
And Consent for Disclosure for Treatment, Payment and Operations

ACKNOWLEDGMENT AND CONSENT
By signing below, I hereby acknowledge that I have been provided with a copy of this office's Notice of Privacy Practices and have therefore been advised of how my protected health information may be used and disclosed by the office and how I may obtain access to and control this information. In addition, by signing below, I hereby consent to the use and disclosure of my health information for treatment purposes, payment activities and healthcare operations of the office as described in the Notice.


Signature of the Patient or Personal Representative

Print Name of Patient or Personal Representative (including description of legal authority)


Date

This document is informational only and does not constitute legal advice. Dentists must consult with their private attorneys for such advice.