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:
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:
_____Employee Initials