Patient Consent/Acknowledgement Form (HIPAA)

Paul A. Bruggeman D.D.S., P.C. | Kevin M. Bruggeman, D.D.S.

Please correct the errors described below.

By signing below, you consent to the use and disclosure of your protected health information by Drs. Paul and Kevin Bruggeman, our staff, and our business associates for treatment, payment and health care operations. For a more detailed description of uses and disclosures for these purposes, please review our Notice of Information Practices (“Notice”). You have the right to review our Notice prior to signing this consent. The terms of this Notice may change. If the terms do change, you may obtain a revised Notice by simply contacting this office at (815)455-3123 and requesting a revised Notice. We will also post any revised notice in the waiting room at the office.

You have the right to request that we restrict our uses or disclosures of your protected health information that we are otherwise permitted to make for treatment, payment and health care operations, although we are not required to agree to these restrictions. However, if we agree to further restrictions, they are binding on us. Finally, you may refuse to consent to the use or disclosure of your protected health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Protected Health Information (PHI).

This form is also used to obtain acknowledgment of receipt of OUR NOTICE of privacy practices or to document our good faith effort to obtain that acknowledgment.

I understand and agree to the sharing or disclosure of information for the following specific instances by this office:

  • Any health, dental, or psychological history recorded as a patient’s dental record to Doctors, healthcare institutions, or insurance companies via telephone, fax, or electronically.
  • Medical allergies or conditions that would dictate a change in the routing procedure will be posted in a conspicuous manner on the patient’s chart to ensure patient safety.
  • Planned treatment may be discussed via mail, telephone, answering machines, email, and fax to numbers/addresses of the patient’s choosing. Prescription information can be confirmed via mail, telephone, answering machines, emails, and faxes to numbers/addresses of the patient’s choosing.

Access to patient’s information will be limited to health care providers, health care institutions, patient’s insurance company, immediate family members or significant other.


have been offered a copy of this office’s Notice of Privacy Practice and have (circle on) declined or received as such.

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.