13DS7943
OFFICE ESSENTIALS
SUPPLIES FOR YOUR EVERYDAY NEEDS
June 30–September 29, 2013
GET
EDUCATED!
el s
Mod
g
rushin
es
3B
ochur
Br
tient
3Pa harts
C
Wall
3
ks
g Boo
Codin
3
HA
ts
A / OcS Produc
mA
3H IoP plian e
C
THOROFARE PROFESSIONAL GROUP
500 GROVE ROAD
THOROFARE, NEW JERSEY 08086
(800) 555-1234
Notice of Privacy Practices
Patient Acknowledgement
Patient Name: _____________________________________________
Date of Birth: ___________________________
I have received and understand this practice’s Notice of Privacy
Practices written in plain language. The notice provides in detail the
uses and disclosures of my protected health information that may be
made by this practice, my individual rights, how I may exercise these
rights, and the practice’s legal duties with respect to my information.
I understand that this practice reserves the right to change the terms
of its Notice of Privacy Practices, and to make changes regarding all
protected health information resident at, or controlled by, this practice.
If changes to the policy occur, this practice will provide me a revised
Notice of Privacy Practices upon request.
Signature: ________________________________________________
Date:__________________________________
Relationship to patient (if signed by a personal representative of patient):
_________________________________________________________
Form # PRV2-3
To Order: 1-800-372-4346 8am-9pm (et)
To Fax: 1-800-732-7023
JOIN OUR COMMUNITY
24 Hours
www.henryscheindental.com
http://www.henryscheindental.comhttp://www.henryscheindental.com
Table of Contents for the Digital Edition of Office Essentials - 3rd Quarter 2013