PARENT/GUARDIAN INFORMATION (complete if patient is under the age
of 18)
DENTAL INSURANCE (if applicable)
Enter primary dental insurance information below and upload
photos of insurance card front and back if available.
Enter secondary dental insurance information below and upload
photos of insurance card front and back if available.
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
ATTENTION PATIENT/PARENT/GUARDIAN -PLEASE READ THE FOLLOWING
CAREFULLY
Purpose of consent: By signing this form, the
patient consents to our use and disclosure of the patient’s
protected health information to carry out treatment, payment
activities, and healthcare operations.
Notice of Privacy Practices: The patient has the
right to read our Notice of Privacy Practices before the patient
decides whether to sign this Consent. Our notice provides a
description of our treatment, payment activities, and healthcare
operations, of the uses and disclosures we make of the patient’s
protected health information, and of other important matters about
the patient’s protected health information. We encourage the patient
to read the Notice carefully and completely before signing this
Consent.
We reserve the right to change our privacy practices as described in
our Notice of Privacy Practices. If we change our privacy practices,
we will issue a revised Notice of Privacy Practices, which will
contain the changes. Those changes may apply to any of the patient’s
protected health information that we maintain.
The patient may obtain a copy of our Notice of Privacy Practices,
including any revisions of our Notice, directly from our office at
any time. Contact in person or by the phone and we will mail or fax
a copy to the patient.
Right to Revoke: The patient will have the right to
revoke this Consent at any time by giving us written notice of the
patient’s revocation submitted to our office. Please understand that
revocation of this Consent will not affect any action we took in
reliance on this Consent before we received the patient’s
revocation, and that we may decline to treat the patient or to
continue treating the patient if the patient revokes this Consent.