Purpose of Patient Consent Form

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This form is to obtain your written permission under federal and state law for our use of your patient healthcare records to carry out treatment, payment activities, and health care operations as set forth in our privacy practices Notice. SMILES BY TURLEY requires that each person sign this consent form which authorizes us to share protected health information with other physician offices, your hospital, and your insurance companies. By signing this form, you consent to our use and disclosure of protected health information about you for health care and financial 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.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, the undersigned, acknowledge that I have received a copy of SMILES BY TURLEY'S Notice of Privacy Practices. This notice describes how SMILES BY TURLEY may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and my specific rights regarding my protected health information.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

AUTHORIZATION TO RELEASE INFORMATION TO FAMILY MEMBERS

Many of our patients allow family members such as their spouse, parents, or others to call and request information with respect to evaluation and treatment. Federal and state law precludes us from releasing this information to anyone without the patient's express and written consent. If you wish to have such information released to family members, you must provide authorization. By signing this form, you grant consent to our listing of your general condition in our computer records and our disclosure of your patient health care records to the following persons, including those involved in your care and payment for that care.

You also have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. Be advised, however, that this consent is a condition of treatment by us. If you decide not to sign this consent, we may decline to treat you.

I authorize SMILES BY TURLEY to release my consultation and subsequent treatment plan to the following individuals:

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By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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