ACKNOWLEDGEMENT OF RECEIPT OF

NOTICE OF PRIVACY PRACTICES

Signature Optional 

AUTHORIZATION TO E-MAIL HEALTH INFORMATION TO GENERAL DENTIST OR DENTAL SPECIALIST

 
1. Security Guidelines (HIPAA)

A.     I understand that under the new HIPAA security regulations, that any information regarding my visit to Southern Arizona Endodontics cannot be sent electronically to my General Dentist or Dental Specialist without my written permission, and that the HIPAA Security guidelines are to safeguard my electronic health information. 

B.     The information that will be sent electronically includes the following:

  1. Patient Name
  2. Tooth #
  3. An electronic image of your tooth
No other personal information will be sent electronically (i.e. social security number, or date of birth).

It is important for you to know that SAE understands the importance of keeping personal information protected, and will do everything possible to ensure that protection. 

2. STATEMENT OF UNDERSTANDING

I have received a copy of this office’s Notice of Privacy Practices. I give my permission for my name, tooth #, and electronic image of my tooth to be sent via e-mail to my general dentist, or other dental specialist.

Signed: Date:  

Witness:______________________________________________ Date: _________ 
                                                  (SAE)
 
 

For Office Use Only 

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: