Central VA HIPPA Form
7802 Timberlake Rd. Lynchburg, VA 24502
(434) 385 - 4746
**You may refuse to sign this acknowledgment**
I acknowledge that the orthodontic practice (Central Virginia Orthodontics) provided me with the Notice of Privacy Practices.
Patient's Name:
Patient's Date of Birth:
Patient or Parent/Legal Guardian Signature:
Relationship to patient (If parent or Legal Guardian)
Date:
Shared Information
Please list below anyone you wish to allow access to your medical information. If none, please put a check below.
None
Name of 1st Person:
Relationship of 1st Person:
Phone Number of 1st Person:
Name of 2nd Person:
Relationship of 2nd Person:
Phone Number of 2nd Person:
Name of 3rd Person:
Relationship of 3rd Person:
Phone Number of 3rd Person:
Name of 4th Person:
Relationship of 4th Person:
Phone Number of 4th Person:
You may add to or delete from this list at any time. Please notify us in writing of any changes.