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.

Patient Name(Required)
MM slash DD slash YYYY
Main Contact Number(Required)
Mailing Address(Required)

COMMUNICATING WITH YOU

PHONE NUMBERS TO USE TO COMMUNICATE WITH YOU(Required)
WHERE AND HOW CAN WE LEAVE DETAILED MESSAGES(Required)
WHAT CAN WE COMMUNICATE THROUGH EMAIL

COMMUNICATING WITH YOUR FAMILY, FRIENDS, OR CAREGIVERS

Consent
Spouse/Partner
OTHER PERSON
Check the box next to each type of communication to the family members, friends, or caregivers listed below.
Do Not Include

I understand that emails and text are not always secure ways to communicate and could be intercepted and ready by a third party. I am willing to accept this risk. This practice is not responsible for the privacy or security of your health information once it is sent to you, or the recipient(s) listed above.

YOUR PHOTOS & MULTIMEDIA

Photos taken by
PHOTOS/iMAGES MAY BE USED/POSTED

PATIENT RIGHTS & SIGNATURE

*You can end this authorization at any time in writing. See our Notice of Privacy Pratices for exceptions. A termination will not apply to any releases of information that happen before we receive a written termination from you. *The recipient of the information could use or release it in a way that federal or state laws do not protect. This practice is not responsible for the privacy or security of your health information after it is sent to those listed on this authorization. *You can review or copy the information that will be used or released as described in this authorization. *You do not have to sign this authorization to receive treatment from this practice. *You understand that the information that will be used or released might include a communicable disease diagnosis such as HIV or a diagnosis related to mental health or substance abuse unless you exclude it above. *All changes or updates to this form mush be made in writing and signed by you (patient) or your personal representative. Minor edits (e.g., new phone number) can be made on this form, inititaled, and dated instead of requiring new form.
MM slash DD slash YYYY

Acknowledgment of Receipt of Notice of Privacy Policy

I have received a copy of the Notice of Privacy Practices for Plage Dentistry. (Located on the front page of the website)
Patient Name(Required)
Address(Required)
MM slash DD slash YYYY

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

Contact Us

Feel free to contact our office with any questions. We look forward to making each visit to our office a positive experience.

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