HIPAA Patient Consent Form

In April of 2003, new federal requirements regarding privacy of information for health care patients took effect. HIPAA, the Health Insurance Portability and Accountability Act, requires that all medical/dental providers, insurance companies and others put in place controls to ensure that your personal dental/medical information is safe. PLAGE DENTISTRY requests that each patient signs this consent form which allows us to share protected health information with other dental offices and insurance companies. By signing this form, you consent to our use and the disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this consent.

Authorization to Release Information on File

Many of our patients allow family members such as their spouse, parents or others to call and request information. Under the requirements for HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your information released to specific persons, you must authorize and sign this form. Signing this form will give consent to release dental information to the persons indicated below. This consent form will not allow PLAGE DENTISTRY to release any other information to these specified persons.

You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

I authorize PLAGE DENTISTRY to release my dental information to the following individuals: *

  • Authorization to Leave Messages with Noted Persons/Answering Machine

  • *If no person is listed, then I will not allow my dental/medical information to be released to anyone.

If you prefer to download the form instead you can here.