HIPAA Patient Form | Plantation, FL Dentists

Patient Information

First Name*

Last Name*

MI

HIPAA

I acknowledge that a copy of the Notice of Privacy Practice has been made available to me (Copy in our office). I also consent to your disclosure of my information, which you deem necessary in connection with my treatment. I understand that such disclosures may not be of the type listed on separate sheet sheet provided. HIPAA prevents us from disclosing any information about you to anyone (other than your medical and dental providers) without your permission.

List anyone to whom we can release information regarding your treatment.

In accordance with HIPAA Guidelines, we must have permission to call you and/or leave a message. Please update all of the ways we may get in touch with you on your Patient Information Form.

Sign Form

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Relationship to patient*

Name*

Signature*

Today's Date*

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Menu

HIPAA Form

Patient Information

HIPAA

Sign Form

Learn More!