Waukesha Family Dentistry - Acknowledgement of Receipt of Privacy Notice Form

Acknowledgement of Receipt of Privacy Notice

Patient Name(*)

Please provide the patient or guardian's full name.

Date of Birth(*)

Please provide patient's date of birth.

Your privacy and the privacy of your protected health inforamtion is important to us. To provide you with health care, we must share your protected health information. It will be used for treatment, payment, and our health care operations.

Our Notice of Privacy Practice ("NPP") gives you information about how we may use and disclose your protected health information. You have the right to review our NPP before signing this Acknowledgement.

Our privacy practices may change over time. If we change our NPP, we will provide you with a new copy the next time you receive care.

(*)

I understand that checking this box constitutes a legal signature confirming that I have read the above privacy notice. You must agree to the Terms & Conditions to submit this form online.

Electronic Signature(*)

Sign Above

Please provide an electronic signature.