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.
If you are unable to keep a scheduled appointment, a 24-hour notice IS REQUIRED. If less than a 24-hour notice is given, it is considered a “broken appointment”. After 3 “broken appointments”, dismissal from our practice may occur.
The undersigned acknowledges the current effective Notice of Privacy Practices for Drs. Heringhaus General Dentistry. 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 another attending doctor/facility in the future.
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