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I understand that such disclosures may not be of the type listed above. FOR OFFICE USE ONLY Patient refused to sign The following circumstances prohibited the patient from signing the Acknowledgement. For example we make a referral to or consult with another dentist or other health care professional provided a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating your orthodontic treatment. As of March 1st 2012...

The purpose of this Notice is to discuss your choice regarding having your health information distributed and to outline the steps you can take to contribute to the creation and maintenance of your own personalized information. We may ask you for information regarding your wishes before we provide the services you request, or at any other time we may need to access or disclose your information. You have the right to restrict access to your records and to provide us with notice before a record is made public, if doing so will prevent your records from being made available to the public. You can contact us regarding the above relevant information on our contact page. We encourage you to review this Notice of Privacy Practices from time to time and to refer to it at any time in connection with those questions, issues or other matters that may concern you. What information do we collect? We collect personal information about you or that you permit us to collect, including your: Name Address and zip code Email address Name of your spouse/significant other Contact information Phone number (home or cellphone) Name and address of your doctor (if the information on your file indicates that we can make a finding about you through your doctor regardless of your address) When you request an orthodontic evaluation, we collect: Information in your file (or that we may have obtained from you) regarding your orthodontic preferences (including which products you are interested in and how you would like to be treated) and orthodontic experiences (including your opinions, comments and recommendations). We also may collect personal information from you to help us administer our business and provide and fulfill services you have requested, and to provide you with information about the kind of services we provide in each district (for example, our office location and service hours) and the cost of our services. This contact information will be used for internal communications only. The information submitted is strictly confidential and used solely for the purpose outlined in this Privacy Policy, and information may not be used for any other purpose. Who do we share your information with? We share your information with: • any other entity or individual who has a relationship with us and that agrees to comply with this Privacy Policy. That entity or individual will have no access to your personal information. The decision to share information with you will be at the discretion of Michelson Orthodontics, LLC's corporate owner.

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What is acknowledgement for patient form?

The acknowledgement for patient form is a document that confirms the patient's understanding and agreement with the terms and conditions of their healthcare treatment or services.

Who is required to file acknowledgement for patient form?

The patient or their legal representative is required to file the acknowledgement for patient form.

How to fill out acknowledgement for patient form?

To fill out the acknowledgement for patient form, the patient or their legal representative should carefully read the provided information and instructions on the form, and then provide their relevant personal and contact details, sign, and date the form.

What is the purpose of acknowledgement for patient form?

The purpose of the acknowledgement for patient form is to ensure that the patient has received and understood the information about their healthcare treatment or services, and acknowledges their agreement with the terms and conditions.

What information must be reported on acknowledgement for patient form?

The acknowledgement for patient form typically requires the patient's or legal representative's full name, contact information, signature, and date.

When is the deadline to file acknowledgement for patient form in 2023?

The deadline to file the acknowledgement for patient form in 2023 may vary depending on the specific healthcare provider or facility. It is advisable to consult with the respective provider or facility for the exact deadline.

What is the penalty for the late filing of acknowledgement for patient form?

The penalty for the late filing of acknowledgement for patient form may also vary depending on the specific healthcare provider or facility. It is recommended to review the provider's or facility's policies and guidelines to determine the applicable penalties.

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