HIPPA – Health Insurance Portability and Accountability Act
This copy is for you to read and review. You will be asked to sign a paper copy at your first appointment.
Discovery Denture Center, Inc.
Westhill Office Park
1700 Cooper Pt. Rd. S.W. Bldg. #B3
Olympia, WA 98502
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.
Relationship to Patient:___________________________________________________
Dependent family members also covered by this acknowledgement:
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