HIPAA Privacy Form

  • HIPAA PRIVACY FORM

    Acknowledgement of Receipt of Notice
    Of Privacy Practices


    Best Care Dental


    Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to Document our good faith effort to obtain that acknowledgement.
    **You may refuse to sign this acknowledgement**
  • I,
  • , have received a copy/explanation of this office’s Notice of Privacy Practices.
  • Date Format: MM slash DD slash YYYY
  • Authorization to Release Information

  • Purpose: This form is used to obtain authorization to release information regarding you or minor covered under the Privacy Act to people other than yourself.