Acknowledgement of Receipt of Notice of Privacy Practices

Printed Patient Name*
First Last
Patient Birth Date*
MM slash DD slash YYYY
Consent*
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.
I agree to the privacy policy.
Signature of Patient or Patient's Representative/Parent*
Date*
MM slash DD slash YYYY
Printed Name of Patient or Patient's Representative/Parent
Relationship to Patient
Other Persons My Information May Be Shared With:
Relationship