Privacy Policy

Acknowledgement of Receipt of Statement of Privacy Practices

Mill Creek Family Dentistry
16030 Bothell - Everett Highway, Suite 280
Mill Creek, Washington 98012

Ph: 425-481-4974
Ph: 425-337-4001

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Mill Creek Family Dentistry. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibility and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Mill Creek Family Dentistry reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.

Additional Disclosure Authority

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below.
Please only choose one, from member of immediate family, spouse, and other.

Any Member of Immediate Family:
Spouse Only:
Other (Please Specify):

Name of Patient or Personal Representative:
Description of Personal Representative's Authority:

PLEASE MAIL IN OR DIGITALLY SUBMIT YOUR SIGNATURE ON THE FORM BELOW

*I would like to be addressed As:
*Last Name:
Phone Number:
*Email Address:
Date:
I have read and understand this notice. Yes No
Signature: __________________________________________________________________________ Signature of Person Authorized by Law: ________________________________________________

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mail to our address:

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practice over the web digitally.

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