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HIPPA Omnibus Rule

Patient Acknowledgement of Receipt of Notice of Privacy Practices and Consent/Limited Authorization & Release Form

You may refuse to sign this acknowledgement & authorization. In Refusing we may not be allowed to process your insurance claims.

Date(Required)

MM slash DD slash YYYY

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. My signature will also serve as a Phi document release should I request treatment or radiographs be sent to other attending doctor / facilities in the future.

Your Name(Required)

First Last

Sign Your Name(Required)

Legal Representative

Description of Authority

Comments

How do you want to be addressed when summoned from reception area?

First Name Only

Proper Sir Name

Other

How do you want to be addressed when summoned from reception area?

First Name Only

Proper Sir Name

Other

Please list any other parties who can have access to your health information: (This includes step-parents, grandparents, and any caretakers who can have access to this patient's records):

Name

Relationship

Name

Relationship

Confirmation Notifications

I authorize contact from this office to confirm my appointments, treatment, & billing information to be conveyed via:

Cell Phone Confirmation

Home Phone Confirmation

Work Phone Confirmation

Text Message to my Cell Phone

Email Confirmation

Any of the Above

Health Information

I authorize information about my health to be conveyed via:

Cell Phone Confirmation

Home Phone Confirmation

Work Phone Confirmation

Text Message to my Cell Phone

Email Confirmation

Any of the Above

Contact Approval

I approve being contacted about special services, events, fund raising efforts or new health info on behalf of this Healthcare Facility via:

Phone Message

Text Message

Email

Any of the Above

None of the Above

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third-party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you with your knowledge and consent.

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Phone: (302) 838-8306
Email: office@smilebritedelaware.com

Smile Brite Dental Care
300 Biddle Ave., Suite 204
Newark, DE 19702
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