Swanson Dental - Notice of Privacy Practices - Acknowledgement
Notice of Privacy Practices - Acknowledgement
We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to or unless the law requires or compels us to do so. You may see your records or get more information by contacting your Privacy Officer, Nichole Dunham at 425.454.4434.
Assignment & Release:
I authorize the dentist or employer benefit plan to release any information in accordance to HIPAA guidelines required for payment and review of this claim. I hereby authorize insurance benefits to be paid directly to the dentist and I understand I am financially responsible for any balance due. I have reviewed the payment policy.
Name
Name
*
First
Last
Email
*
Draw your signature into the box below.
*
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.
Authorize To Share Health Care Information
If you would like to give us permission to share any information regarding your dental care including appointments, treatment, billing etc with anyone other than yourself please indicate below and sign.
If you do not wish to share any information, please leave portion blank.
You may share the following with:
Name
Name
First
Last
Relationship
Please check all that apply:
Please check all that apply:
All health care information in my dental records
Insurance and billing information
Other (appointments, test results, etc.)
Other Details
This authorization ends:
This authorization ends:
In 90 days from date signed
Never/Until notified otherwise
On a specific date
Specific Date
Specific Date
/
MM
/
DD
YYYY
Draw your signature into the box below.
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.