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Patient Name HIPAA CONSENT 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. For your convenience we take cash check MasterCard visa American Express and Discover. Dishonored Checks A 30. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. Dental History What would you like us to do for...

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