ACKNOWLEDGEMENT
OF
PRIVACY PRACTICES

Discovery Denture Center, Inc.
Westhill Office Park
1700 Cooper Pt. Rd. S.W. Bldg. #B3
Olympia, WA 98502
(360) 943-6290
Fax (360) 943-8505

My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA). I understand that this information can and will be used to:

 Provide and coordinate my treatment among a number of health care providers who may be involved in that
treatment directly and indirectly.

 Obtain payment from third-party payers for my health care services.

 Conduct normal health care operations such as quality assessment and improvement activities.

I have been informed of my dental provider’s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my restrictions, but if you do agree then you are bound to abide by such restrictions.

Patient Name:___________________________________________________________Date:______________________

Signature:______________________________________________________________

Relationship to Patient:___________________________________________________

Dependent family members also covered by this acknowledgement:
_________________________________________________________________________________

________________________________________________________________________________________________

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For Office Use Only:

We were unable to obtain the patient’s written acknowledgement of our Notice of Privacy Practices due to the following reasons:

 The patient refused to sign.  Emergency Situation
 Communication barriers  Other