Patient Acknowledgement and Consent Form

Patient Acknowledgement and Consent Form
Curtis E. Hahn, D.D.S. 4992 Wilson Avenue | Grandville, MI 49418 616.534.0135 | rivertowndental.com
You have the right to read our Notice of Privacy Practices before you sign this Consent.

Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing the Consent.

Click here to read our Privacy Practices

I acknowledge that I have received a copy of this office’s Notice of Privacy Practices:
Name

First NameLast Name
Signature of patient, parent, or legal guardian

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MonthDayYear
Date
I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment:
Signature of patient, parent, or legal guardian

Clear
MonthDayYear
Date
Revocation of Consent
I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations. I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent.
Signature of patient, parent, or legal guardian

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Date:

MonthDayYear
Date
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Patient Acknowledgement and Consent Form

Revocation of Consent