CONSENT FOR USE AND DISCLOSURE of HEALTH INFORMATION

Section A: PATIENT GIVING CONSENT

Name*

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone

Email

Section B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent.

Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

A copy of our Notice accompanies this Consent. We encourage you to read it 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 your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

Contact: Harkins, Hancock & Johnston Dentistry
Telephone: 806-795-4272
Fax: 806-791-2273
E-Mail: info@smilesofwesttexas.com_
Address: 11010 Quaker Ave, Lubbock, TX 79424

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above, Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

Consent

I consent

I have had the full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by checking this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations.

Revocation of Consent

I revoke consent

I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations.

I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent.

Date

Are You a Personal Representative Signing on Behalf of Patient?

Yes
No

If you are a parent signing on behalf of a minor/student or a spouse completing for the patient, choose yes.

Personal Representative’s Name

First

Last

Relationship to Patient

DISCLOSURE TO OTHER NON-MEDICAL PERSONS

Yes
No

I authorize my dental information to be disclosed to the following persons.
– If a minor or student, include parents
– Consider if other individuals such as a spouse or employer should know your patient health history.

Include Name, Address, Phone and Relationship to Patient

Multiple people can be included in separate rows.

HIPPA Compliance

CONSENT FOR USE AND DISCLOSURE of HEALTH INFORMATION

Section A: PATIENT GIVING CONSENT

Section B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY