Form

530 Chauvet Drive
Pittsburgh, PA 15275
Tel: (412) 876-8003
E-Mail: info@terrificteethpd.com

HIPAA Notice of Privacy Practices

I understand that, under the Health Insurance Portability & Account Act of 1996 (HIPAA), I have certain rights to privacy regarding my Protected Health Information (PHI).

I understand that this information can and will be used to:

Conduct, plan, and direct my treatment and follow-up among the multiple health care providers who may be involved in the treatment directly or indirectly
Obtain payment from third party payers
Conduct normal healthcare operations

I have read and understand that I may submit a written request how my PHI is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by them.

Parent/Guardian Signature

Date

I hereby acknowledge that I have received a copy of this offices Notice of Privacy Practices. I may refuse to sign this acknowledgement. To obtain a paper copy I may request it from the office or the website.

First Name

Last Name

Signature

Date