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HIPAA Acknowledgement Form

To complete this HIPAA Acknowledgement Form, simply fill out the fields with the requested information. While most of the fields are optional, certain fields marked by asterisks (*) must be completed. Please do not use your browser's Back or Forward buttons. Use of these buttons may “undo”/”redo” recent actions. Once you have completed this document, simply click the submit button to proceed.


I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

-Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly

-Obtain payment from designated third-party payers.

-Conduct normal health care operations such as quality assessments or evaluations, and physician certifications.

I have been informed by you of your Notice of Privacy Practices that contains a more complete description of the uses and disclosures of my health information (available at the following link HIPAA Notice of Privacy Practices or in office in print form).

I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that San Diego Dental Health Center has the right to change its Notice of Privacy Practices from time to time and that I may contact San Diego Dental Health Center at any time to obtain a current copy of the Notices of Privacy Practices.

I understand that I may request in writing that San Diego Dental Health Center restricts how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand San Diego Dental Health Center is not required to agree to my requested restrictions, but if San Diego Dental Health Center does agree, then it is bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that San Diego Dental Health Center has taken action relying on this consent.

By checking the box I acknowledge that
Please draw your signature in the box. Use the X to clear your signature.

Please carefully review your information before submitting this document.