Hipaa Omnibus Rule - Blue Wave Orthodontics

Date

Patient Name

How Do You Want To Be Addressed When Summoned From Reception Area:

Other

Please List Any Other Parties Who Are Actively Involved In Your Health Care And Who Can Have Access To Your Health Information:
(This includes step parents, grandparents and any care takers who can have access to this patient's records):

Name

Relationship

Name

Relationship

I Authorize Contact From This Office To Confirm My Appointments, Treatment & Billing Information Via:

I Authorize Information About My Health Be Conveyed Via:

I Approve Being Contacted About Special Services, Events, Fund Raising Efforts Or New Health Info On Behalf Of This Healthcare Facility Via:

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.

Please print name of Patient

Please sign Patient / Guardian of Patient

Legal Representative / Guardian

Relationship of Legal Representative / Guardian

As Privacy Officer, I attempted to obtain the patient's (or representatives) signature on this Acknowledgement but did not because:

Other (please describe)

Signature of Privacy Officer

Patient Acknowledgement Form For Receipt Of Notice Of Privacy Practices Consent/limited Authorization & Release Form

OFFICE USE ONLY: