Patient Consent for use and Disclosure of Protected Health Information
With my consent, Sierra Orthodontics, may use and disclose my/ my child's protected health information to carry out treatment, payment and healthcare operations.
Please refer to Sierra Orthodontics Notice of Privacy Practices for a more complete description of such uses and disclosures.
I have the right to review the Notice of Privacy Practices prior to signing this consent.
Sierra Orthodontics reserves the right to revise its Notice of Privacy Practice at any time.
With my consent, the office may call my home or other designated locations and leave a message on voice mail or to the person who answers in reference to any items that assist treatment, such as appointment reminders, insurance items, financial questions and any call pertaining to my clinical care including laboratory results.
With my consent, the office may mail to my home or other designated location any items that assist the practice, such as appointment reminder cards and patient statements.
For minor children
With my consent, the office may share treatment care and results with the person that accompanies my child to the orthodontic appointment.
In the case of dual guardianship, both guardians may be contacted about the patient's appointments, treatment progress, and financial information. However, the office will not share either guardian's phone numbers, social security numbers or addresses with the other guardian. Only the patient's information will be shared.
By signing this form, I am consenting to Sierra Orthodontics use and disclosure of my/ my child's personal Health Information needed to carry out treatment.