HIPAA

ACKOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

You may refuse to fill out this acknowledgement. By filling out this form, you are verifying that you have received a copy of this office's Notice of Privacy Practices

I am the “personal representative” and have legal authority to make health care decisions about the following patient:

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  • Authorization of additional disclosure:

    I authorize the following individuals to have access to my health information.
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  •   I give Northgate Dental permission to leave phone messages on any of my phone contacts.
  •   Please contact me personally and DO NOT leave messages
  •   I give Northgate Dental permission to leave messages only on the following phone numbers:
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  • security code
    Enter Security Code: