HIPAA Form
I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to: 1) Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly . 2)Obtain payment from third-party payers. I have been offered or read Philip Wolkstein, DMD, Inc., Greg Wolkstein, DDS, Dentistry for Children and Young Adults Notice of Privacy Practices containing more complete description of the uses and disclosures of my protected health information. I understand that Philip Wolkstein, DMD, Inc., Greg Wolkstein, DDS,Dentistry for Children and Young Adults has the right to change its Notice of Privacy Practices from time to time and that I may contact Philip Wolkstein, DMD, Inc., Greg Wolkstein, DDS, Dentistry for Children and Young Adults at any time to obtain a current copy of their Notice of Privacy Practices.
Name of Patient (First and Last Name)
If you are signing on behalf of the patient as a parent or legal guardian, please enter your name and relationship to the patient below
By selecting "I accept," you are indicating your acknowledgment of the above information and that all the information provided on this form is true and accurate, to the best of your knowledge.
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