Notice of HIPAA, Teledentistry and Non-Secure Communications

I acknowledge that I have a received a copy of Dr. Marshall’s “Notice of Privacy Practices (HIPAA),” "Notice of Teledentistry and Non-Secure Communications," and "Patient Advisory and Acknowledgment: Receiving Dental Treatment During the COVID-19 Pandemic."

I understand that I should ask the Privacy Official at Dr. Marshall’s office, if I have any questions regarding these policies and procedures.

Date*

Date

Patient Name*

First NameLast Name

Patient's Date of Birth*

Date

Please pick one:*

I am the patient, filling out this form for myself.I am a legal guardian of the patient, filling out this form on behalf of the patient.

Legal Guardian Name*

First NameLast Name

Patient Signature (or signature of parent/legal guardian)*

I would like a copy of "Notice of Privacy Practices (HIPAA), Teledentistry and Non-Secure Communications" emailed to me at:

example@example.com

Patient Age

Notice of Privacy Practices (HIPAA), Teledentistry and Non-Secure Communications, COVID-19 Advisory & Acknowledgement

Acknowledgement - Receipt of Notice of Privacy Practices