HIPAA Release Form

HIPAA Release Form

HIPAA Release Form

HIPAA Release Form

HIPAA Release Form

About Cossich Family Dentistry

Cossich Family Dentistry provides the highest quality, compassionate eye care to ensure your family enjoy a long, happy, and healthy life.

HIPAA

Cossich Family Dentistry complies with the guidelines described in the privacy practice act located in the reception room.

​​​​​​​I hereby acknowledge that I have had an opportunity to review Cossich Family Dentistry Notice of Privacy Practice located in the reception room. I understand that I may ask any questions I have regarding this Notice.
Patient’s Name (PRINT)
Patient/Parent Signature
Date