NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT AND PATIENT CONSENT FORM
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:
I authorize the staff of Scott Leinassar, D.M.D. and Andrea Leinassar, D.D.S. to leave a message on my answering machine regarding:

Yes
No
Yes
No
Yes
No

Also, if I am not available, I authorize the staff of Scott Leinassar, D.M.D. to speak with the individual(s) listed below regarding my care.
Name of IndividualRelationship to PatientPhone Number


Yes
No

Yes
No

I have received, read, and understood your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change it's Practices from time to time and that I may contact this organization at any time at the address above to obtain my 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 healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.


Submit this form automatically to Smith Valley Smiles