PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability & Accountability Act of 1996, I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used.

• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third party payers.
• Conduct normal healthcare operations such as quality assessments and physician certifications.
  I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at anytime at the address above to obtain a current copy of the Notice of Privacy Practices.
  

I understand that 1 may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand 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 CONSENT FORM

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its notice from time to time and that I may contact this office at any time to obtain a current copy of the Notice of Privacy Practices.
1 understand that I may revoke this consent in writing at any time, except to the extent that you taken action relying on this consent.

PATIENT RECORDS ACCESS REQUEST & PERMISSION FORM

I hereby request a copy of my dental record as detailed below: [ ] Full dental record held by this office
[ ] Dental record for the period___________________through_________________.
[ ] A specific portion/section of the record as follows:
    _______________________________________________________________

    _______________________________________________________________

[ ] 1 hereby grant the office permission to contact me at work concerning my healthcare. [ ]I hereby give the office permission to leave the appropriate messages on my answering device concerning my healthcare.

Patient Name _____________________________________________________

Relationship to the Patient __________________________________________

Signature ________________________________________________________

Date ____________________________________________________________

Raymond F. Tinucci, D.M.D.
Family Dentistry
Voice 610.326.8770
Fax 610.326.3935
703 High Street
Pottstown, PA 19464