ACKNOWLEDGEMENT

OF

PRIVACY PRACTICES

Richard S. Nicklas DDS

497 South Wall Street

Kankakee, IL 60901

 

My signature confirms that I have been informed of my rights to privacy regarding my protected health information under the Health Insurance Portability & Accountability Act or 1996 (HIPPA).  I understand that this information can and will be used to:

 

  • Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly or indirectly.
  • Obtain payment from third-party payers (insurance companies) for my health care services.
  • Conduct normal health care operations such as quality assessment, improvement, and normal business operations.

 

I have been informed of my dental provider’s Notice of Privacy Practices, containing a more complete description of the uses and disclosures of my protected health information.  I have been given the right to review and to receive a copy of such Notice of Privacy Practices.  I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices at any time.

 

I understand that I may request in writing that this office restrict how my private information is used or disclosed in carrying out treatment, receiving payments, or in health care operations in general.  And, I understand that this office is not required to agree to my requested restrictions and still retain me as a patient.  But, if this office does agree to my personal restrictions, is bound to abide by such an agreement.

 

Patient Name:____________________________________ Date:________________________

 

Signature:_______________________________________

 

Relationship to Patient:_____________________________

 

For Office Use Only:

We were unable to obtain the patient’s written acknowledgement of our Notice of Privacy Practices due to the following reason:

  • The patient refused to sign
  • Communication barriers
  • Emergency Situation
  • Other:___________________________________

_____Employee Initials