Form

Notice of Privacy Practices Acknowledgement Form

Patient's Name: (First Name, Last Name)

Date Of Birth

I understand that as part of my dental care, Venetia Laganis, D.D.S, M.S creates and maintains health records that describe my health history, dental information, symptoms, examinations, test results, diagnosis, procedures, treatment, and future care or treatment I may receive. I understand that health information collected and stored will be used for the following;

* To support my care and treatment at Venetia Lganis D.D.S, M.S (treatment)

* For continued treatment among health professionals who are involved and contribute to my health care (treatment)

* For billing purposes including information regarding my diagnosis, treatment, and services rendered (payment)

* A tool for routine healthcare operations such as assessing quality improvement (healthcare operations)

I understand that the Notice of Privacy Practices from Venetia Laganis D.D.S, M.S defines more information regarding the use and disclosure of my protected health information as well as my rights to my health information.

By signing this, I ackowledge that Dr. Venetia Laganis, D.D.S, M.S has offered me a copy of their Notice of Privacy Practices.

I acknowledge and understand the rights that I have over my protected health information.

I authorize the use and disclosure of my protected health information as specified in the Notice Of Privacy Practices.

I authorize the use and disclosures for treatment, payment, and healthcare operations purposes for Venetia Laganis, D.D.S, M.S.

I authorize Venetia Lganis, D.D.S,M.S to communicate regarding my dental treatments to the following individual(s):

First Name

Last Name

First Name

Last Name

I understand that I am ultimately responsible for all charges incurred for dentistry performed at Venetia Laganis, D.D.S, M.S office including balances left after insurance payment has been received.

I understand that Venetia Laganis, D.D.S,M.S communicates through test messaging about appointment reminders that contain specific patient information. I agree to the communication through text messaging unless I select the box below.

I do not wish to receive text message communication for appointment reminders (check to opt out)

This consent will continue forever unless I cancel it by writing to: Venetia Laganis, D.D.S, M.S, 7767 Elm Creek Blvd, Suite 110, Maple Grove, MN, 55369; if the consent is cancelled, it will not change releases that have already been made prior to the date of cancellation. Please complete ONLY if you want the consent to expire on a specific date.

I wish the consent to expire on (date)

Date

I understand that I can get an electronic copy of the Notice of Privacy Practices at www.laganispediatricdentistry.com.

Patient's Signature/Legal Representative Signature

Date

If Legal Representative, relationship to Patient

Optional: Please e-mail me a copy of the Notice of Privacy Practices to the following e-mail address

Internal Use:

If patient refuses to sign, please have 2 staff members of Venetia Laganis, D.D.S, M.S sign below

Signature