HIPAA

Name: Kirkpatrick & Lai Orthodontics
Address: 5304 S Harvard Ave, Tulsa, OK
Telephone: 918-747-1346
Price range: $
Rating: 99

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES *Please Note: I may refuse to sign this acknowledgment. I have been offered and/or received a copy of Drs. Kirkpatrick and Lai's Notice of Privacy Practices. I understand that my PHI (Protected Health Information) can and will be used for purposes of treatment and for payment from both myself and/or third party. I understand that I may request a copy of the privacy policies at any time.*

Printed Patient Name:
Date
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Patient Signature (18+ years of age)
Patient Signature (18+ years of age)
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Parent/Guardian Signature*
Parent/Guardian Signature*
Relationship to Patient*

Name and relationship for each person to whom you authorize release of information to:

Expires 3 Years from Initial Signature*
Date:
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Expires when patient reaches the age of 18*
Date of Age 18:
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