Consent for Use and Disclosure of Health Information

Please correct the errors described below.

SECTION A: PATIENT GIVING CONSENT

SECTION B: TO PATIENT - PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND SIGN

Purpose of Consent: By signing this form,, you will consent to our use and disclosure of your protected health information in order to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide to sign this Consent. Our Notice provides a description of our treatment, payment activities and healthcare operations and how it effects your protected health information. A copy of the Notice of Privacy Practices accompanies this consent form. Your personal information and dental record have always been handled with the utmost of confidentiality. We are committed to continue our practice in the same manner that allows you to enjoy the highest level of dental care we can provide while protecting your information. We are required by the Federal Law (HIPPA) Health Insurance Portability and Accountability Act to share with you just how your information may be disclosed. This is the Reason for reading the Notice of Privacy Practices and signing this Consent form. You are entitled to a copy of this form after you sign it.

As stated in our Notice of Privacy Practices, we reserve the right to change /revise / update our Notice. If changes are made, we will issue a revised Notice reflecting any changes made. You may obtain additional copies of our Notice of Privacy Practices, including any revisions at any time by contacting Gerald M. Winkler, DMD in writing at the address listed above.

Right to Revoke: You have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the address of Dr. Gerald M. Winkler noted above. Please understand revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and we may decline to treat you or to continue treating you if you revoke this Consent.

Signature of Patient / Parent / Guardian / Patient Representative:

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.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

(You may refuse to sign this acknowledgment)

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.

Patient / Parent / Guardian / Patient Representative

FOR OFFICE USE ONLY

Documentation of Good Faith Efforts

and was provided with a copy of Covered Entity’s Notice of Privacy Practices. A good faith effort was made to obtain from the patient a written acknowledgement of his/her receipt of the Notice.

Such acknowledgment was not obtained for the following reason:

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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