Order Number Farmington Family Dental 34405 Grand River Ave., Farmington, MI 48335 | 248-478-3285 | Fax: 248-478-9398 PRIVACY PRACTICES STATEMENT HIPPA ACKNOWLEDGEMENT OF RECEIPT I acknowledge that I have access to a copy of the Notice of Privacy Statement (HIPPA) from this office I have read this Privacy Statement and any questions I had, have been answered by the office staff. Patient Name * Email Address * Electronic Signature Aggreement * I ACCEPT. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. Digital Signature * Today's Date *
