ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES 2013 Murphy Dental 608 East Harmony Road, Suite 301 Fort Collins, CO 80525

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1 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES 2013 Notice to Patient: We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement, if you wish. I acknowledge that I have received a copy of this office's Notice of Privacy Practices. Please print yourname hem Signature FOR OFFICE USE ONLY We have made every effort to obtain written acknowledgment of receipt of our Notice of Privacy from this patient but it could not be obtained because: The patient refused to sign. Due to an emergency situation it was not possible to obtain an acknowledgement We weren't able to communicate with the patient. Other (Please provide specific details) Employee signature i HIPAA Acknowledgement of Receipt of the Notice of Privacy Practices 2013 i

2 CONSENT FOR USE / DISCLOSURE OF HEALTH INFORMATION Murphy Dental 608 East Harmony Road, Suite 301 Fort Collins, CO Patient' s Name: Patient's of Birth: Patient's SSN: Notice to Patient: By signing this form, you grant us consent to use and disclose your protected health care information for the purposes of treatment, various activities associated with payment and health care operations. Our Notice of Privacy Practices provides more details on our treatment, payment activities and health care operations. If there is not a copy of the Notice accompanying this Consent form, please ask for one. We encourage you to read it since it provides details on how information about you may be used and/or disclosed and describes certain rights you have regarding your health care information. As stated in our Notice of Privacy Practices, we reserve the right to change our privacy practices. If we should do so, we will issue a revised Notice. Since revisions may apply to your health care information, you have a right to receive a copy by contacting our Privacy Officer. You have the right to revoke your Consent by giving written notice to our Privacy Officer. The revocation will not affect actions that were already taken in reliance upon this Consent. You should also understand that if you revoke this Consent we may decline to treat you. You are entitled to a copy of this Consent Form after you have signed it. (To Be Completed by Patient or Patient's Representative) I,, have read the contents of this Consent Form and the Notice of Privacy Practices. I understand that I am giving you my consent to use and disclose my health care information to carry out treatment, payment activities and health care operations. Patient's Signature or Signature of Patient's Representative Printed Name of Patient's Representative Relationship to Patient Our Privacy Officer can be contacted as follows: Name of Privacy Officer: Amber Tripp Practice Address: 608 East Harmony Road, Suite 301 Fort Collins, CO Phone: Fax: E Mail: MurphyDental@gmail.com i HIPAA Consent for Use / Disclosure of Health Information

3 Consent to Communicate Patient Name: Please mark the ways that you consent to us communicating with you: Method Ok to Leave Voic Ok to Leave Message with Another Person Preferred Contact Method(s) O Call Work Phone 0 Yes 0 No 0 Yes 0 No 0 0 Call Cell Phone 0 Yes 0 No 0 Yes 0 No 0 0 Call Home Phone 0 Yes 0 No 0 Yes 0 No 0 0 Send Appointment Reminders 0 Medical Information 0 Send Text Message I I 0 0 Text Appointment Reminders O Send Regular Mail I - I - I 0 0 Mail to which address: 0 Home 0 Other (please list): I authorize the following individuals to inquire and receive information regarding my care: Name Relationship Phone DOB Any Comments Signature: :

4 MURPHY DENTAL OFFICE POLICIY AND CONSENT FORM Please remember that we are here to serve you in a comfortable and professional atmosphere. Our goal is to provide you with the very best quality of dental core. OFFICE POLICIES Your appointment time is set aside especially for you. We ask for courtesy to Dr. Murphy and to other patients that you keep your scheduled appointments. If you must change or miss an appointment we would appreciate a 48hr notice. Less than a 24hr cancellation or failure could result in a broken appointment charge of $60.00 or no re-appointment. We realize that many families are in state of change. The policy in our office is that the parent who request treatment for a child is responsible to us for all fees incurred. We will be fair in working out finances with you, but please also be fair to us with your commitments. A 1.5% finance charge will be assessed monthly on all overdue balances. Please note for your convenience we do accept VISA, MasterCard, Discover, and Care Credit as well as checks and cash. All E4D procedures must pre-pay. I understand and agree that a photograph may be taken of me for identification purposes or for other treatment purposes, INSURANCE AND PAYMENT POLICIES FEE FOR SERVICE AT OUR OFFICE WILL BE REQUESTED ATTHE TIME OF YOUR VISIT FOR PATIENTS WITH AND WITHOUT DENTAL INSURANCE. FOR PATIENTS WITH DENTAL INSURANCE: We are committed to provide you with the best possible care. If you have dental insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve this goal, we need your assistance, and your understanding of your payment policy. We will be happy to process your insurance claim for your reimbursement. We will answer any questions relating to your insurance but you must realize, however, that: o Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. o Most insurance companies have a deductible that must be met before the company will pay their portion. If you have not met your deductible for the year, you are responsible for any charges until the deductible is met. Even after the deductible is met, insurance companies only pay a percentage up to the yearly allowance and you will be responsible for the remainder. o Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. o Any claims unpaid after 90 days will automatically become patient responsibility. o Collections: In the event Murphy Dental, in its sole discretion, commences collection action against PATIENT for nonpayment or partial payment of services, ALL attorney fees, collection fees, filing fees, and all associated fees with the pursuit of collections will be patient responsibility. WE MUST EMPHASIZE THAT AS A DENTAL CARE PROVIDER OUR RELATIONSHIP IS WITH YOU NOT YOUR INSURANCE COMPANY. WHILE FILING OF THE INSURANCE CtA1MS IS A COURTESYTHAT WE EXTEND TO OUR PATIENTS. ALL CHARGES ARE YOUR RESPONSIBILITY FROM THE DATE OF SERVICE PROVIDED Consent: I understand that responsibility for payment of medical services in this office for myself and dependents is mine; due and payable at the time of services are rendered unless financial arrangements have been made. I understand that I am responsible for all cost of collections including attorney fees, collection fees and court costs. I understand that any unpaid balance will be assessed interest at the rate of 18.00% (1.5%) monthly. Insurance claims are filed as a courtesy, but it Is my responsibility to see that the claims are paid. I fully understand I am responsible for payment of fees not covered by Insurance. I also assign all benefits to Michael P. Murphy DDS. I acknowledge that my signature on this document authorizes the submission of claims without obtaining my signature on each and every claim submitted. I give my authorization and consent for treatment, alternatives, and risks by my doctor. I have been advised of my privacy rights as provided by the Healthcare Information Portability and Accountability Act of Responsible Party's signature

5 AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS TO REQUEST RELEASE OF MEDICAL INFORMATION PLEASE COMPLETE AND SIGN THIS FORM. I., hereby voluntarily authorize the disclosure of information from my health record. (Name of Patient) Patient Information: Patient Name: Address: Record Number. of Birth: Information Requested: Purpose of Release: The Information Is To Be Provided To: Name of Person/Organization/Facility: Address: Phone Number. Patient's Signature or Patient's Representative Printed Name of Patient's Representative Relationship to Patient This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose. Under HIPAA with a patient's written request, records must be provided within 30 days of a request. PLEASE MAKE A COPY OF THIS RELEASE FOR YOUR RECORDS. 1 HIPAA Authorization For Release Of Medical Records