Notice of Privacy Practices Acknowledgement

1. Notice of Privacy Practices Acknowledgement Palm Tree Dental

2. Notice of Privacy Practices Acknowledgement I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: 1.Conduct, plan and direct my treatment and follow-up among multiple healthcare providers who may involve in that treatment directly and indirectly. 2.Obtain payment from third-party payers. 3. Conduct normal healthcare operations such as quality assessments and physician certifications. I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures or my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact Palm Tree Dental Center at any time the address above to obtain a current copy of the Notice of Privacy Practices. If you request copies of your clinical records, we will charge you $1.00 each report page, $5.00 for each film sheet and $15.00 per hour of staff time to locate and copy your health information, and postage if you want the copies mailed to you. (Continued on next page)

3. Notice of Privacy Practices Acknowledgement Medical Release Medical Release A photocopy of this document shall be sufficient to authorize any person having records of medical treatment, services or supplies pertaining to me to release true copies of same to PALM TREE DENTAL CENTER or any other insurer providing coverage to me in connection with the processing of any claim for benefits made by me or by the assignee herein. A photocopy of this document shall be as binding as an original signature page. The undersigned does hereby ratify and confirm any and all actions taken by the said attorney in accordance with this special power and which the said attorney shall do or cause to be done by virtue of these patients. Assignment of Benefits I hereby authorize my Health Insurance Carrier to make medical benefits payments otherwise payable to me for services rendered by PALM TREE DENTAL, but not to exceed the charges of those services, payable to an mailed directly to: Palm Tree Dental Center 6200 20th street #292 Vero Beach, FL 32966 Furthermore, I hereby IRREVOCABLY ASSIGN to PALM TREE DENTAL CENTER the rights and benefits under any policy of insurance, indemnity agreement or any other collateral source as defined in Florida Statues for any service and or charges provided by PALM TREE DENTAL CENTER. In Witness whereof the undersigned have hereunto set their hands: Today’s Date:_____________________________________ Patient’s Signature/Legal Guardian_________________________________________________ Patients Name/Legal Guardian___________________________________________ (Please Print) P:772-778-5773 F:772-778-6944 – 6200 20th Street #292 Vero Beach, Florida 32966 www.palmtreedental.com