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: