Washing Township Dental
Pediatric Medical History
Mary-Kathryn Annuzzi D.M.D.
Annie Creato D.M.D.
474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080
856-582-1000


Mononucleosis, tuberculosis (TB), scarlet fever, cytomegalovirus, methicillin resistant staphylococcus aureaus (MRSA), sexually transmitted disease (STD), or human immunodeficiency virus (HIV)/AIDS


Over the couter rinse School fluoride program
Pediatrician applied fluoride Prescription fluoride toothpaste
Prescripiton drops/tablets/vitamins

The information on both pages of this form is accurate and complete to the best of my knowledge. Any errors or omissions in completing this form is solely my responsibility.
Signature of parent/guardian
Relationship to Patient
Date
Washing Township Dental
HIPAA
474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080
856-582-1000

HIPAA OMNIBUS RULE - Patient Acknowledgement of Receipt of Notice of Privacy Practices and Consent/limited authorization & release form. You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

The undersigned acknowledges having had full opportunity to read and consider the contents of this HIPAA Consent form and the Notice of Privacy Practices. The undersigned understands that, by signing this consent form, they are giving consent to use and disclose their protected health information to carry out treatment, payment activities, insurance and any other office procedures. A copy of this signed and dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTORS/FACILITIES IN THE FUTURE.

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide this information with your knowledge and consent.



PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
(This includes step-parents, grandparents, and/or any caretakers who can have access to this patient's records):

I AUTHORIZE Contact from this office to confirm my appointments, treatment, and billing information via:
I AUTHORIZE Contact from this office to information about my health via:
I AUTHORIZE Contact from this office to special services, events, fund raising efforts, or new health info via:

Your comments regarding Acknowledgement or Consents
Office Use Only As privacy officer, I attempted to obtain the pateint's (or representative's) signature on this Acknowledgement, but did not because:
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