Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of receipt of notice of Privacy Practices

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 form**

I,
Name*
have been made aware of this office’s Notice of Privacy Practices and have received a copy of the Notice of Privacy Practices if I have so requested.
Name*
Signature
Date*
Month
Day
Year
I,
Name*
the undersigned, hereby authorize Orthodontic Specialists, doctor and staff, to share any and all dental and financial information with the following individual(s) on behalf of myself or my child,
Child Name*
.

Name	Relationship to Patient

- At this time I do not authorize anyone other than parent/guardian.
I understand that authorization to anyone other than myself and child’s other parent is voluntary and I can revoke authorization at any time:
Authorized by:
Patient/Parent Name

Phone Number

(570) 346-1822

E-Mail

reception@orthospecs.com

Address

Orthodontic Specialists
1640 Main Street
Dickson City, PA 18447

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