Patient Consent for Use and Disclosure of Protected Health Information
Please correct the errors described below.
This authorization form permits Redbank Family Dentistry to use or disclose protected health information listed in the Description section below to the Entity/Person listed in the Receiving Entity section for the following patient:
Receiving Entity: Please check the boxes for those entities or persons you wish to get the described information about you.
Description of information to be given to checked Entity or Person.
General viewing and Social Media viewing By checking all of these boxes, we will be able to reply to you on social media and/or Google if leaving us a review or have any questions regarding our practice.
The purpose of this authorization is to meet the patient's request for information disclosures and uses.
Rights of the Patient
I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.
I understand that I have the right to revoke this authorization at any time by sending a written notification to the address listed at the top of this form I understand that a revocation is not effective in cases where the information has already been used or disclosed but will be effective going forward.
I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.
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