Form

Bahri Dental Group

Your Privacy Is Important to Us

Acknowledgement of Receipt of Notice of Privacy Policies

I have received the option to request a copy of the Notice of Privacy Practices for Bahri Dental Group. I hereby authorize, as indicated by my signature below, Bahri Dental Group to use and to disclose my protected health information for any necessary clinical, financial, and insurance purpose, as authorized in the Patient Consent form.

Fill out 1 form per patient.

First Name

Last Name

Date Of Birth

You may contact me at my home telephone number.

Phone

You may contact me at my cell telephone number.

Phone

You may contact me at my work telephone number .

Phone

You may contact me at my email.

Other

Please Explain

Please list authorized persons with whom we may discuss your Protected Health Information (PHI) in addition to custodial parents and legal guardians:

Person 1

Person 2

Person 3

Person 4

Patient/Legal Guardian Signature

Date