Privacy Form

First Name:

Last Name:

Birthdate:

Occasionally it becomes necessary to share dental records/information with insurance companies and consulting/co-treating doctors. With your permission we electronically transmit this information.

PLEASE LIST ANY OTHER PARTIES 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:

Name:

Relationship:

*You May Refuse to Sign This Acknowledgement*
I have been given the opportunity to review the Notice of Privacy Practices. I understand that a hard or electronic copy is available to me if I request a copy.

Signature:

Date: