Patient Acknowledgement and Consent Form

Please note that it is important to fill in all the fields before submitting. Thank you.

Patient Name :
*Last Name:
Middle Name: *First Name:
Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) requires that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future.
To comply with one of HIPAA’s requirements, we make available to you a copy of our Notice of Privacy Practices. This Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices.
Existing Michigan Law requires (in addition to our attempt to obtain your written acknowledgement, discussed above) us to first obtain your written consent prior to disclosing any of your information except for our disclosures in connection with: a defense to a claim challenging our professional competence; a review entity’s functions; a claim for payment of fees; a third party payer’s examination of our records; a court order as part of a criminal investigation; an identification of a dead body; a licensure investigation; or a child abuse/neglect investigation.
From time to time it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we may make a referral to or consult with another dentist or other health care professional, provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating your treatment.

Patient Acknowledgement & Consent
Please sign this form below to acknowledge that you are aware that a copy of our notice of privacy practices is available as well as to consent to our disclosures of your information that we deem necessary in order to provide you with proper treatment.

* I acknowledge and consent to the above information

*Signature :
Date :

If you wish to authorize us to release medical or financial information about you to spouse, partner, friends or relatives, please list them below:
Name : Relationship :
Name : Relationship :
Name : Relationship :