Welcome to Our Office!

PATIENT INFORMATION: PATIENTS UNDER 18 YEARS OF AGE

RESPONSIBLE PARTY INFORMATION

DENTAL INSURANCE INFORMATION

ORTHODONTIC GOALS

DENTAL HISTORY


MEDICAL HISTORY

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.