I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective care provider or agency, who may release such information to you.
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Patient acknowledgement form for receipt of notice of privacy practices consent/limited authorization & release form.
You may refuse to sign this acknowledgement & authorization. In refusing, we may not be allowed to process your insurance claims.