ACKNOWLEDGEMENT
OF
PRIVACY PRACTICES

Dr. Paul Stadler DDS
620 S. Main St.
Shrewsbury, PA 17361

My signature confirms I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to

    Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly.

    Obtain payment from third-party payers for my health care services.

    Conduct normal health care operations such as quality assessment and improvement activities.

I have been informed of my dental provider's Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review ad receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Patient Name: ____________________________  Date: ______________
 
Signature:____________________________________________________
 
Relationship to Patient: __________________________________________
 
Dependent family members also covered by this acknowledgement:
_____________________________________________________________
_____________________________________________________________

............................................................................................................................................................................

For Office Use Only
We were unable to obtain the patient a written acknowledgement of our Notice of Privacy Practices due to the following reason:

     The patient refused to sign
     Communication barriers
     Emergency situation 
     Other