ACKNOWLEDGEMENT NOTICEOF PRIVACYPRACTICES Michael Stafford.D.D.S..P.A. Eric B. Hollander,D.D.S. 5414ParkcrestDr. Austin,Texas78731 I have Portability Actof 1996("H|PAA"), & Accouniability I understand that,undertheHealthInsurance canand I undersland thatthisinlormation myprotected healthinlormation. certainrightsto privacyregarding willbe usedto: . Conduct,planand direclmy treatmentand follow-upamongthe multiplehealthcare providerswho may be involvedin that lreatmentdirectlyand indlrectly. ' Obtainpaymentfromlhird-partypayers. . Conductnormalhealthcareoperationssuchas qualityassessments and physician certitications. I havereceived,readand understandyout Noticeof PrivacyPracticesconlaininga morecomplete I understandthat this organization descriptionof the usesand disclosuresof my healthinformation. lime lo time and that I mayconlactthis ot Privacy Practices lrom haslhe rightto changells Notice organizationat any time at the addressaboveto obtaina currentcopyof the Noticeol Private Practices. is usedor I understandthat I may requestin writingthat you restricthow my privateinformation disclosedto carryout treatment,paymentor healthcareoperations.lalso understandyou are not but if you do agreethenyou are boundto abideby requiredto agreeto my requestedrestrictions, suchrestrictions. PatienlName to Patient: Relationship Signature: Date OFFICEUSEONLY on this Noticeol PrivacyPractices lattemptedto obtainthe patient'ssignaturein acknowledgement Acknowledgement, butwas unableto do so as documentedbelow:
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