ACKNOWLEDGEMENT OF PRIVACY RIGHTS
My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance & Accountability Act of 1996 (HIPAA I understand that this information can and will be used to: 1. Provide and coordinate my treatment among a number of health care providers who may be involved in the treatment directly or indirectly. 2. Obtain payment from third-party payers for my health care services. 3. 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 practices. I understand that my dental provider has the right to change the Notice of Privacy Practices, and that I may request to obtain a current copy.
I understand that I may request in writing that this office restrict how my private information is used or disclosed to carry out treatment, payment or health care operation. I understand that the office is not required to agree to my requested restrictions, but if the office does agree then it is bound to abide by such restrictions.