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 or Parent/Legal Guardian Signature:



Shared Information

Please list below anyone you wish to allow access to your medical information. If none, please put a check below.

You may add to or delete from this list at any time. Please notify us in writing of any changes.