Notice of Private Practices

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HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health/dental information is used and disclosed. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare/dental information. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

  • Protected health/dental information may be disclosed or used for treatment or payment.
  • The practice reserves the right to change the privacy policy as allowed by law.
  • The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
  • The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
  • This practice will verify the identity of anyone requesting protected health information. Verification information will be the child’s date of birth.

May we phone, email, or send a text to you to confirm appointments?     Yes      No
May we leave a message on your answering machine at home or on your cell phone?   Yes    No   May we send the school or the employer absentee excuses?   Yes    No
May we discuss your child’s dental condition with any member of your family?      Yes      No
If YES, please name the members allowed and their relationship to the child:




Child’s name: _______________________________________________________

This consent was signed by: (Print Name)____________________________________________

Relationship to Child ____________________________

Signature: ____________________________________________ Date: ___________