Welcome to Our Office!
PATIENT INFORMATION: PATIENTS UNDER 18 YEARS OF AGE
RESPONSIBLE PARTY INFORMATION
DENTAL INSURANCE INFORMATION
NOTICE OF PRIVACY ACTS CONSENT FORM
I understand that I have certain rights given to me under the Health Insurance Portability and Accountability Act (HIPPA) regarding
my protected health information. I understand that by signing this consent I authorize you to use and disclose my protected health
information for the following:
- Treatment including that given by all health care providers involved in my care.
- Obtaining payment from third party payers including insurance companies and other paying parties.
- The day-to-day health care practices of the orthodontic practice.
I have also been informed that I may request a copy of the Notice of Privacy Practices containing a more complete description of
the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy
Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy or
the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment,
payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do
agree then you are bound to abide by such restrictions.
I understand that I may ask that this consent be revoked but I must do so in writing. However, any use or disclosure that occurred
prior to the date is not affected.