Exceptional Needs Dental Services

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Forms

Authorization to Release Patient Records Form (PDF)

Financial Responsibility Form (PDF)

Consent for Hospital Based Dental Care (PDF)

Notice of privacy practices (Word)

Receipt acknowledgement of HIPAA (Word)

Receipt acknowledgement of notice of privacy practices (Word)

 

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Exceptional Needs Dental Services
12029 NE Sumner St | Portland, OR 97220
Local: 503.295.1201 | Toll Free: 800.644.1859 | Fax: 503.295.1211