This form is optional under the new patient privacy regulations recently issued by the United
States Department of Health and Human Services. We have elected to use this form. Prior to
commencing your orthodontic treatment, you should review, sign and date this form.
Your protected health information (i.e., individually identifiable information such as names,
dates, phone/fax numbers, email addresses, home addresses, social security numbers, and
demographic data) may be used in connection with your treatment, payment of your account or
health care operations (i.e., performance reviews, certification, accreditation and licensure).
You have the right to review our office's privacy notice prior to signing this Consent, a copy
of which was given to you with this Consent. You have the right to request restrictions on the
use of your protected health information. However, we are not required to, and may not, honor
We may amend the attached privacy notice at any time. If we do, we will provide you with a copy
of the changes, and the changes may not be implemented prior to the effective date of the
You may revoke this Consent at any time in writing. However, such a revocation will not be
effective to the extent that any action has been taken in reliance on this Consent.
Thank you for your cooperation. Please let us know if you have any questions.