Practice Marketing & Office Supply Catalog 2021/2022 - 157
MEDICAL HISTORY * HIPAA ACKNOWLEDGEMENT FORMS
A. ADA® 2021 HEALTH HISTORY FORMS
(368-3628)
Front
(Back not shown)
* Reflects the latest AHA premedication guidelines
* Clear, 2-sided layout and simple wording
* Includes questions related to intravenous bisphosphonates and
alendronates
Forms��������������������������������������������������������������������100 per Pad
Specify:
Adult-English
Adult-Spanish
Child-English
CLINICAL FORMS
D
A
Front
35.99
(368-3628)
(368-3629)
(368-3630)
Back
D. NOTICE OF PRIVACY PRACTICES FORM
B
THOROFARE PROFESSIONAL GROUP
500 GROVE ROAD
THOROFARE, NEW JERSEY 08086
(800) 555-1234
Notice of Privacy Practices
Patient Acknowledgement
Patient Name: _____________________________________________
Date of Birth: ___________________________
* Available in a handy padded format
* 100 sheets per pad
* If you purchase D, you must purchase B or C
* 81⁄2 " W x 11 " H, 5 lines
(367-3437)������������������������������������������������������5 Pads per Pkg.
4 Pkg.@
43.99
41.99
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):
_________________________________________________________
B. NOTICE OF PRIVACY PRACTICES
PATIENT ACKNOWLEDGEMENT
SHORT FORM
E
F
Form # PRV2-3
* Padded form documents patient's receipt of
your privacy policy in succinct, easy-to-understand terms
* 25 sheets per pad
* 51⁄2 " W x 81⁄2 " H, 5 lines
3-Part-25 sheets per pad
(367-3435)������������������������������������������������������5 Pads per Pkg.
4 Pkg.@
G
62.99
60.99
C
E-G. HIPAA NOTICE OF PRIVACY PRACTICES PRODUCTS
C. NOTICE OF PRIVACY PRACTICES
PATIENT ACKNOWLEDGEMENT
* Document patient's receipt of your
privacy policy
* 3-part form includes a copy for the patient,
their chart, and a copy for the Privacy Officer's file
* 2-hole punched at top
* 81⁄2 " W x 11 " H, 5 lines
(367-3436) ������������������������������������������������������������������������100 per Pkg.
73.99
E. Brochure
Trifold brochures measure 11 " W x 81⁄2 " H when flat, 35⁄8 " W x 81⁄2 " H when folded
(367-0208)�����������������������������������������������������������100 per Pkg.
36.99
5 Pkg.@
34.99
F. Acknowledgement Labels
4 " x 2 "
(367-4180)�����������������������������������������������������������100 per Pkg.
25.99
5 Pkg.@
23.99
G. Acknowledgement Labels
4 " x 1 "
(367-3088)�����������������������������������������������������������100 per Pkg.
19.99
5 Pkg.@
17.99
For Imprinted Materials, contact: professional.promotions@henryschein.com
To order, visit: www.henryscheindental.com
157
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Practice Marketing & Office Supply Catalog 2021/2022
Table of Contents for the Digital Edition of Practice Marketing & Office Supply Catalog 2021/2022
Contents
Practice Marketing & Office Supply Catalog 2021/2022 - Cover1
Practice Marketing & Office Supply Catalog 2021/2022 - Cover2
Practice Marketing & Office Supply Catalog 2021/2022 - Contents
Practice Marketing & Office Supply Catalog 2021/2022 - 2
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Practice Marketing & Office Supply Catalog 2021/2022 - Cover3
Practice Marketing & Office Supply Catalog 2021/2022 - Cover4
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