HIPAA Privacy Form

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  • HIPAA PRIVACY FORM

    Acknowledgement of Receipt of Notice
    Of Privacy Practices


    Best Care Dental

    Purpose: 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 acknowledgement**
  • I,
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  • , have received a copy/explanation of this office’s Notice of Privacy Practices.
  • MM slash DD slash YYYY

  • Authorization to Release Information

  • Purpose: This form is used to obtain authorization to release information regarding you or minor covered under the Privacy Act to people other than yourself.