ࡱ> egd YbjbjSS 4&11+ -\\,*ccc*******-70*cA"ccc*\\9*7!7!7!c"\8*7!c*7!7!V(@)`848) t**0*D)x0~0))0)cc7!ccccc**7!ccc*cccc0ccccccccc ": Tim Smith Dental 6439 Old Jacksonville Highway Tyler, Tx. 75703 (903) 592-5934 www.timsmithdental.com ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM You may refuse to sign this acknowledgement but, in refusing we will not be allowed to process your insurance claims. Date: __________________ The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for Dr. Timothy R. Smith, D.D.S. 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 OTHER ATTENDING DOCTORS IN THE FUTURE. ______________________________________ ________________________________ Please print your name Please sign your name _______________________________________ ________________________________ Legal Representative Description of Authority PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR DENTAL INFORMATION: (This includes step parents, grandparents and any care takers who can have access to this patients records): Name: ________________________________ Relationship: ______________________________ Name: ________________________________ Relationship: ______________________________ Name: ________________________________ Relationship: ______________________________ -------------------------------------------------------------------------------------------------------------------------------------------- I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY DENTAL APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA: Cell Phone Confirmation _________________________________________________________ Home Phone Confirmation _______________________________________________________ Work Phone Confirmation_________________________________________________________ Text Message to my Cell Phone Email Confirmation_______________________________________________________________ U. S. Mail / Postcard Any of the above I AUTHORIZE INFORMATION ABOUT MY DENTAL HEALTH BE CONVEYED VIA: Message on Cell Phone Message on Home Phone Message on Work Phone Email Message U. S. Mail / Postcard Any of the above ------------------------------------------------------------------------------------------------------------------------------------------- Office Use Only As Privacy Officer, I attempted to obtain the patients (or representatives) signature on this Acknowledgement but did not because: It was emergency treatment _____ I could not communicate with the patient _____ The patient refused to sign _____ The patient was unable to sign because _____ Other (please describe) _____ ____________________________________________  Signature of Privacy Officer HIPAA made EASY All Rights Reserved 2012 .>?g  ' 8 9 ttttfXDXt&h\ h\ 6>*CJOJQJ^JaJh\ CJOJQJ^JaJh4CJOJQJ^JaJhI(CJOJQJ^JaJh&CJOJQJ^JaJ#hxhPv5CJOJQJ^JaJhl:]5CJOJQJ^JaJhPv5CJOJQJ^JaJh&5CJOJQJ^JaJ#hxh&5CJOJQJ^JaJh.I)5CJOJQJ^JaJhO:5CJOJQJ^JaJ/@Ofg J K L e f $ V W X < gdkgd_)$a$gd_)gd&$a$gd&9 B C J K L e f  = ? $ + 0 : G ´¦|e|WBW)hkh&56>*CJOJQJ^JaJhkCJOJQJ^JaJ,h1lh_)5B*CJOJQJ^JaJphh_)CJOJQJ^JaJhPvCJOJQJ^JaJhU&CJOJQJ^JaJh&CJOJQJ^JaJh8JCJOJQJ^JaJ h8Jh8JCJOJQJ^JaJ h8Jh&CJOJQJ^JaJhI(CJOJQJ^JaJh\ CJOJQJ^JaJG K V W < ? ^   a b PQy|||hWF hkhkCJOJQJ^JaJ hI(5>*CJOJQJ^JaJ&hkhk5>*CJOJQJ^JaJ h8Jh8JCJOJQJ^JaJ hI(hI(CJOJQJ^JaJ hI(hq:CJOJQJ^JaJ hI(h)WCJOJQJ^JaJh8JCJOJQJ^JaJh&CJOJQJ^JaJhkCJOJQJ^JaJ)hkhk56>*CJOJQJ^JaJ<   a b Qa"8IJ & Fgdk & Fgdfw & Fgdkgd&gdk(`x!"8IVx亨ucR>&hkh&5>*CJOJQJ^JaJ h8JhkCJOJQJ^JaJ#hkhk5CJOJQJ^JaJhS,aCJOJQJ^JaJ hkhkCJOJQJ^JaJ&hkhk5>*CJOJQJ^JaJ#hkhfw5CJOJQJ^JaJh]CJOJQJ^JaJhCCJOJQJ^JaJhqCJOJQJ^JaJhkCJOJQJ^JaJhSCJOJQJ^JaJ#$P+<VWXY$a$gdac^gd^ ^gd&gd&gdkgdk & Fgdkyzi*+:<UVWXY瀞|plhhO:hachacCJ OJQJaJ hacCJ OJQJ^JaJ hac56CJ OJQJ^JaJ hac56CJ OJQJaJ hkhMCJaJ5jhac5CJOJQJU^J_HaJmHnHuh8JCJOJQJ^JaJ hkhCJOJQJ^JaJ hkh&CJOJQJ^JaJ21h:p.I)/ =!"#v$h% j, 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XVx OJPJQJ_HmH nH sH tH @`@ &NormalCJ_H aJmH sH tH Z@Z  Heading 1$<@&5CJ KH OJPJQJ\aJ \@\  Heading 2$<@& 56CJOJPJQJ\]aJV@V  Heading 3$<@&5CJOJPJQJ\aJJ@J  Heading 4$<@&5CJ\aJN@N  Heading 5 <@&56CJ\]aJH@H  Heading 6 <@&5CJ\aJ::  Heading 7 <@&@@@  Heading 8 <@&6]N @N  Heading 9 <@&CJOJPJQJaJDA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List RoR Heading 1 Char5CJ KH OJPJQJ\aJ ToT Heading 2 Char 56CJOJPJQJ\]aJNoN Heading 3 Char5CJOJPJQJ\aJBo!B Heading 4 Char5CJ\aJHo1H Heading 5 Char56CJ\]aJ:oA: Heading 6 Char5\<oQ< Heading 7 CharCJaJBoaB Heading 8 Char6CJ]aJ@oq@  Heading 9 Char OJPJQJR>@R Title<@&a$5CJ KHOJPJQJ\aJ JoJ  Title Char5CJ KHOJPJQJ\aJ BJ@B Subtitle <@&a$ OJPJQJFoF  Subtitle CharCJOJPJQJaJ*W`* `Strong5\:X`: @Emphasis56OJQJ]4@4  No SpacingaJ @@@  List Paragraph ^m$*@* !Quote 68o8  Quote Char 6CJaJH@H # Intense Quote "]^ 56aJFo1F "Intense Quote Char 56CJBaAB 0Subtle Emphasis 6B*phZZZJaQJ PIntense Emphasis56>*CJaJDaaD Subtle Reference >*CJaJDaqD Intense Reference 5>*CJFaF  Book Title56CJOJPJQJaJ6 6 p TOC Heading)@& H@H +q0 Balloon Text*CJOJQJ^JaJRoR *q0Balloon Text CharCJOJQJ^J_H aJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! 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X-  !1.@"Arial------ #2 6a0 Tim Smith Dental     2 60    72 E50 6439 Old Jacksonville Highway     2 E0    "2 Uf0 Tyler, Tx. 7570  2 U0 3  2 U0    2 dl 0 (903) 592  2 d0 - 2 d0 5934  2 d0    ,2 sG0 www.timsmithdental.com      2 s0     2 0    a2 90 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES                 2 0    2 0 AND CONSENT/    2 <0 LIMITED    52 u0 AUTHORIZATION & RELEASE FORM          2 ]0   @"Arial------ 2 0 You   2 0 m  2 0 ay   2 0 r 2  0 efuse to   2 H0 s 2 O 0 ign this   2 }0 a  2 0 cknowledgement    2 0   2  0 but, in refus 2 00 ing we    2 \0   @"Arial--------- (2 0 will not be allowed---  2 f0   #2 m0 to process your   2 0 i 2  0 nsurance   2 0 c 2 0 laims.   2 30  @ Arial------- @ !i- @"Arial------  2 `0     2 `0   --- /2 `0 Date: __________________   2 0   ---  2 `0   --- 2 `j0 The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for       2 0   @"Arial---------  2 `0   52 d0 Dr. Timothy R. Smith, D.D.S.         2 0   2 0   2   0 A copy of th  "2 i0 is signed, date 2  0 d document   2 0   D2 &0 shall be as effective as the original. 2 0   --- 2 `U0 MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR           g2 .`=0 RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTORS IN THE FUTURE.         2 .0   ---  2 >`0     2 M`0    D2 \`&0 ______________________________________ 2 \u0    2 \0    2 \0  0 2 \ 0 _________ .2 \0 _______________________  2 \0   @"Arial--------- 2 l`0 Please --- 2 l0 print---  2 l0   2 l 0 your name   2 l0    2 l0  0  2 l 0  0  2 lP0  0  2 l0  0  2 l0  0 2 l0 Please --- 2 l 0 sign---  2 l&0   2 l, 0 your name   2 li0  @ Arial------- @ !m- - @ !m -  ---  2 {`0     2 `0    2 ``0 _______________________________________ ________________________________   2 0    )2 `0 Legal Representative   2 0    2 0    2 0  0  2  0  0  2 P0  0  2 0  0  2 0  0 /2 0 Description of Authority    2 i0     2 `0    82 `0 PLEASE LIST ANY OTHER PARTIES         R2 F/0 WHO CAN HAVE ACCESS TO YOUR DENTAL INFORMATION:             2 0   @"Arial- - - - - -  2 `0 (Th :2 r0 is includes step parents, grand j2 ?0 parents and any care takers who can have access to this patient   2 l0  2 o 0 s records):  2 0   --- 2 `Z0 Name: ________________________________ Relationship: ______________________________      2 0   ---  2 `0   --- 2 `0 Name:    2 0   2 S0 ________________________________ Relationship: ______________________________    2 0   ---  2 `0   --- 2 ``0 Name: ________________________________ Relationship: ______________________________       2 0   ---  2 (`0   --- w2 8`H0 ------------------------------------------------------------------------ q2 8D0 --------------------------------------------------------------------  2 80   --- G2 G`(0 I AUTHORIZE CONTACT FROM THIS OFFICE TO            --- 82 G0 CONFIRM MY DENTAL APPOINTMENTS            2 G0 , @ Arial- - - - - - - @ !H-  --- :2 V`0 TREATMENT & BILLING INFORMATION          ---  2 VW0   2 V^0 VIA:    2 Vw0  - @ !W`-  ---  2 c`0   @Wingdings 2- - - - - - - - -   2 rr0 * ---  2 r{0   .2 r0 Cell Phone Confirmation      2 r0   [2 r50 _____________________________________________________ 2 r0 ____  2 r0   - - -   2 r0 * ---  2 {0   .2 0 Home Phone Confirmation       2 $0   ^2 +70 _______________________________________________________  2 0   - - -   2 r0 * ---  2 {0   .2 0 Work Phone Confirmation     a2 90 _________________________________________________________  2 0   - - -   2 r0 * ---  2 {0   72 0 Text Message to my Cell Phone      2 E0   - - -   2 r0 * ---  2 {0   &2 0 Email Confirmation    J2 *0 __________________________________________ +2 .0 _____________________  2 0   - - -   2 r0 * ---  2 {0   +2 0 U. S. Mail / Postcard      2 0   - - -   2 r0 * ---  2 {0  --- #2 0 Any of the above   2 0   ---  2 `0   --- 2 ` 0 I AUTHORIZE    --- >2 "0 INFORMATION ABOUT MY DENTAL HEALTH           ---  2 0   #2 0 BE CONVEYED VIA:      2 V0  - @ !-  ---  2 `0   - - -   2 x0 * ---  2 0   +2 0 Message on Cell Phone     2 0   - - -   2 x0 * ---  2 0   +2 0 Message on Home Phone      2 )0   - - -   2 'x0 * ---  2 '0   +2 '0 Message on Work Phone     2 '$0   - - -   2 6x0 * ---  2 60   2 6 0 Email Message    2 60   - - -   2 Ex0 * ---  2 E0   +2 E0 U. S. Mail / Postcard      2 E 0   - - -   2 Ux0 * ---  2 U0  --- #2 U0 Any of the above   2 U0   ---  2 a0   --- 2 p` 0 --------- 2 p}0 ----------------------------------------------------------------------------------------------------------------------------- 2 p0 -----  2 p0   @"Arial- - - - - -  "2 }`0 Office Use Only  2 }0  @ Arial- - - - - - - @ !Q~`- --- e2 `<0 As Privacy Officer, I attempted to obtain the patients (or  "2 l0 representatives >2 "0 ) signature on this Acknowledgemen  ,2 c0 t but did not because:  2 0     2 `0    42 0 It was emergency treatment    2 0    2  0  0  2 P0  0 2  0 _____   2 0    G2 (0 I could not communicate with the patient   2 O0    2 P0  0 2 0 _____  2 0    42 0 The patient refused to sign  2 0    2  0  0  2 P0  0 2 0 _____  2 0    D2 &0 The patient was unable to sign because   2 N0    2 P0  0 2 0 _____  2 0    .2 0 Other (please describe)  2 0    2  0  0  2 P0  0 2 0 _____  2 0    22 `0   2 ]0   M2 ,0 ____________________________________________  2 0   @"Calibri--------- 2 `u0   2 0   52 0 Signature of Privacy Officer---  2 E0   --$nn  n---- $nn  --' o@"Century Gothic------ "2 o HIPAA made EASY  2 o   2 o   @"Century Gothic------ 12 o All Rights Reserved 2012  2 o   '"SystemuR-40&u@)uƴ@0--  00//..՜.+,0$ hp  Toshiba%  :ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Title  !"#$%&'()*+,./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[]^_`abcfRoot Entry F̥8h1Table1WordDocument4&SummaryInformation(-\DocumentSummaryInformation8\CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q