Acknowledgement of Receipt of Notice of Privacy Practices View Privacy Policy "*" indicates required fields Name* First Last Patient Birth Date* Month Day Year Consent* I agree to the privacy policy.We at Hinke Family Dentistry are required by law to maintain the privacy of and provide individuals with the attached Notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to the Notice, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. If you would like a copy of the Notice, please ask. I hereby acknowledge that I have reviewed the HIPAA Notice of Privacy Practice document.Signature*Date* MM slash DD slash YYYY Printed Name of Patient or Patient's Representative/ParentRelationship to PatientOther Persons My Information May Be Shared With:Relationship to Patient
