 Acknowledgement
of Receipt of Notice of Privacy Practices and Consent Form
The
text of the notice appears below. You may download the form in Adobe
Acrobat PDF format by clicking on the image to the right. You may
then print,
sign, and bring the
form with
you during your next appointment.
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James
D. Thomas, DDS, P.C.
ACKNOWLEDGEMENT
OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT FORM
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 are giving 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.
PLEASE SIGN
THIS FORM BELOW UNDER THE HEADING “PATIENT
ACKNOWLEDGMENT” TO ACKNOWLEDGE THAT YOU HAVE TODAY RECEIVED
A COPY OF OUR NOTICE OF PRIVACY PRACTICES.
Existing Michigan Law requires (in addition to our attempt to
obtain your written acknowledgment, 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.
PLEASE SIGN
THIS FORM BELOW UNDER THE HEADING “PATIENT
CONSENT” TO CONSENT TO OUR DISCLOSURES OF YOUR INFORMATION
THAT WE DEEM NECESSARY IN ORDER TO PROVIDE YOU WITH PROPER TREATMENT.
PATIENT ACKNOWLEDGEMENT
By signing below, I acknowledge that I have today
received the Notice of Privacy Practices from this practice.
I understand that routine protocol in the office includes the
use of a sign-in sheet upon arrival, confirmation messages may
be left on answering machines, voice mail, or with another individual
answering the telephone regarding appointments if the patient
is not available. I understand that postcards may be used to
remind patients of future appointments or need for them. The
office may remind patients to take medications prior to the appointment
when leaving messages. The office may also use electronic mail
(e-mail) to communicate with patients.
_______________________________
{Patient Signature}
_______________________________
{Please Print Name}
_______________________________
{Date}
PATIENT CONSENT
I consent to your disclosures of my information,
which you deem are necessary in connection with my treatment.
I understand that such disclosures may not be of the type listed
above.
_______________________________
{Patient Signature}
_______________________________
{Please Print Name}
_______________________________
{Date}
A copy of this signed form (including electronic storage and retrieval) will
be considered the same as the original.
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