Troy Orthodontics - Privacy Form

Acknowledgement of Receipt of Notice of Privacy Practices

(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

*You May Refuse to Sign This Acknowledgement*

I have been provided the opportunity to read and receive a copy of this office's Notice of Privacy Practices.

Patient's First Name:

Last Name:

Birthdate:

If acknowledgement is by patient's personal representative:

I certify that I have the authority under applicable law to act on behalf of the patient identified above.

E-Signature of Patient/Personal Representative:

Relationship to Patient:

Date:

If you would like a copy of our Notice of Privacy Practices for your personal records, please ask our staff for a copy to go!

It is our policy not to allow cell phones, video recorders or cameras into our clinical areas. This is to ensure that our patient privacy is kept at all time. We apologize for any inconvenience this may cause you.