Jacobson & Tsou Orthodontic HIPAA and PHI Form

* You May Refuse to Sign This Acknowledgement*

I have received a copy of this office′s Notice of Privacy Practices.

Print Patient Name:

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Signature:

Date:

E-mail Statement and Acknowledgment:

It is our office′s goal to keep your information confidential and secure. Being that most E-mail systems are unencrypted, there are inherent risks with E-mail (e.g. interception, alteration). If you understand the risks associated with E-mail and would still like to be communicated with in that way, please acknowledge below.

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Right to Revoke

I have the right at any time to revoke this Acknowledgement for any reason. I have the right to sign this portion at a later time/date of my choice to revoke my Acknowledgement.

Acknowledgement of Receipt of Notice of Privacy Practices

* You May Refuse to Sign This Acknowledgement*

Personal Health Information Disclosure Agreement

Jacobson and Tsou Orthodontics