Michael J. Hoffman DDS, P.C.

15340 23 Mile Rd

Macomb, MI 48044

Phone: 586-247-8730 Fax: 586-247-8734

Patient Acknowledgement and Consent Form

Effective April 14, 2004, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) requires that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future.

To comply with one of HIPAA’s requirements, we are giving you a copy of our Notice of Privacy Practices. This Notice of Privacy Practices contains the information the HIPAA requires us to disclose regarding our privacy practices. Existing Michigan Law requires (in addition to our attempt to obtain your written acknowledgement, discussed above) us to first obtain your written consent prior to disclosing any of your information except for our disclosures in connection with: a defense to a claim challenging our professional competence, a review entity’s functions; a claim for payment of fees; a third party payer’s examination of our records; a court order as part of a criminal investigation; an identification of a dead body; a licensure investigation; or a child abuse/neglect investigation.

From time to time it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we may make a referral to or consult with another dentist or other health care professional, provide specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating your treatment.

Patient Acknowledgement

Please sign this form below under the heading “acknowledgement” to acknowledge that you have today received a copy of our Notice of Privacy Practices.

I acknowledge that I have received a copy of the Notice of Privacy Practices.

For Office Use Only

Patient Refused To Sign

The following circumstances prohibited the patient from signing the Acknowledgement: ________________________________________________________________________

An emergency situation prevent the patient from signing the Acknowledgement. ________________________________________________________________________

Office Personnel (Signature)        Office Personnel (Print Name)             Date

Patient Consent

Please sign this form below under the heading “Consent” to consent to our disclosures of your information that we deem necessary in order to provide you with proper treatment.

I consent to your disclosures of my information, which you deem necessary in connection with my treatment. I understand that such disclosures may not be of the type listed above. I also authorize Dr Hoffman and staff to discuss my treatment with the following individual (s):