Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accountability Act of
1996 (“HIPAA”) requires that this office comply with certain rules regarding the maintenance of the privacy of your
information that we have collected and will collect in the future.
To comply with one of HIPAA’s requirements, we are giving you a copy of our Notice of Privacy Practices. This notice
of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices.
Existing Michigan Law requires (in addition to our attempt to obtain your written acknowledgment, discussed above)
us to first obtain your written consent prior to disclosing any of your information except for our disclosures in
connection with: a defense to a claim challenging our professional competence; a review entity’s functions; a claim
for payment of fees; a third party payers examination of our records; a court order as part of a criminal
investigation, an identification of a dead body; a licensing investigation; or a child abuse/neglect investigation.
From time to time it may be necessary for us to make disclosures of your information in connection with your
treatment. For example, we may make a referral to or consult with another dentist or other health care professional,
provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with
providing or coordination your treatment
Patient Acknowledgment of Receipt of Notice of Privacy Practices
*You May Refuse to Sign This Acknowledgement*
Please sign this form under the following statement to acknowledge that you have today received a copy of our
Notice of Privacy Practices.