Form

ACKNOWLEDGEMENT OF RECEIPT OF STATEMENT OF PRIVACY PRACTICES

I acknowledge that I received a copy of the Statement of Privacy Practices for the offices of Sue Vetter, DDS, PLLC. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respects to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Sue Vetter, DDS, PLLC reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revises Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

ADDITIONAL DISCLOSURE AUTHORIZATION

In addition to the allowable disclosures described in the Statemen of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare information to the person(s) identified below. (I understand that the default answer is " NO." Without indicating "YES" in answer to each individual question, protected health information (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

Spouse Only

Any Member of my Immediate Family: (Spouse, Children Siblings, etc)

Any Member of my Extended Family: (Parents, Grandparents)

Other:

Patient's First Name

Patient's Last Name

Date Of Birth

Patient's Personal Representative Name

Patient's Personal Representative Phone Number:

Patient/Legal Guardian Signature

Date

OFFICE USE ONLY BELOW THIS LINE

ACKNOWLEDGEMENT NOT OBTAINED

Provided Prior to Treatment?

Date

Reasons for not obtaining Patient Signature: