ACKNOWLEDGEMENT
OF
PRIVACY PRACTICES
LakeRidge Dental Partners
Woodbridge                                         Alexandria
12500 Lake Ridge Dr.                          8403-I Richmond Hwy
Woodbridge VA 22192                        Alexandria, VA 22309
(703) 494-3176                                    (703) 360-1070

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

            ٱ Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly
            ٱ Obtain payment from third-party payers for my health care services
            ٱ Conduct normal health care operations such as quality assessment and improvement activities

I have been informed of my dental provider's Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy practices. I understand that my dental provider has the right to change the Notice of Privacy practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that i may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bounded to abide by such restrictions.

Patient name: _____________________________            Date: ________________________ 

Signature: ___________________________________
Relationship to Patient: ____________________________

Dependent family members also covered by this acknowledgment.
______________________________________________________________________________ ______________________________________________________________________________
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For Office User Only::
We were unable to obtain the patient's written acknowledgment of our Notice of Privacy Practices due to the following reason:

            ο The patient refused to sign
            ο Communication barriers
            ο Emergency situation
            ο Other: ______________________________________________________________________________