notice of privacy practices acknowledgement Please review this DOCUMENT first, you may submit the form electronically below, or print this FORM off and bring it into the office. Des Moines River Dental Care PLLC NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I understand that under the Health Insurance Portability & Accountability act of 1996("HIPPA"), I have certain rights to privacy regarding my protected health information(PHI). I understand that this information can and will be used to: -Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment, directly and indirectly -Obtain payment from third-party payers -Conduct normal healthcare operations such as quality assessments and physician certifications I received, read, and understood your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my PHI. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of this Notice of Privacy Practices. I understood everything I read. Yes Date:
