Patient Authorization Form

Patient Acknowledgement of Receipt of Notice of Privacy Practices and Consent / Limited Authorization & Release Form

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process insurance claims.

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. My signature will also serve as a PHI document release should I request treatment or radiographs be sent to other attending doctor / facilities in the future.

How do you want to be addressed when summoned from the reception area?
I authorize contact from this office to confirm my appointments, treatment & billing information via:
I authorize information about my health be conveyed via:
I approve being contacted about special services, events, fund raising efforts or new health info via:

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

Clear Signature

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Sarah Palmer DDS and Amy Harmon DDS are able to restore teeth to their natural appearance and function with porcelain crowns or other cosmetic dental services. If you are interested in learning if you are a candidate for our porcelain crown treatments, call our cosmetic dentists at (616) 534-0080.

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