Patient Acknowledgement of Privacy Practices

By signing below, you acknowledge that you have reviewed and received a copy of this office's Notice of Privacy Practices explaining:
How this office will use and disclose my protected health information
My privacy rights with regard to my protected health information
This office's obligations concerning the use and disclosure of my protected health information.

I understand that the Notice of Privacy Practices may be revised from time to time and that I am entitles to receive a copy of any revised Notice of Privacy Practices upon request.

I also understand that if I have any questions or complaints, I may contact:

Drake Family Dental
Phone: (717) 267-1288
Email: [email protected]
Address: 4202 Philadelphia Ave, Chambersburg, PA 17202

You May also contact the Secretary of the U.S. Department of Health and Human Services with any concerns regarding our privacy and security policies and procedures. Please contact our office for information on how to contact the U.S. Department of Health and Human Services.

Patient or Personal Representative

Signature

Date

Name

First Last

Relationship to Patient