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Consent For Treatment

Patient Details
  1. Sex:
Facility Details
Privacy Information
  1. In accordance with the Privacy Regulations created by the Health Insurance Portability and Accountability Act of 1996 (HIPPA), we are required to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information that describes how we may use and disclose your protected health information to carry out treatment, payment of health care operation and for other purposes that we are permitted or required by law.

    We will use and disclose your protected health information to provide, coordinate, or manage your dental care and any related services. For example: your health/dental information may be provided to a dentist to whom you have been referred to ensure that the dentist has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information periodically to another dentist, physician or health care provider who becomes involved in your care.

    We may use and disclose dental information about you in order to obtain payment for services rendered. Such disclosures may be made to you, an insurance company, responsible party or third party. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover treatment.

Responsibile Party Details
Fee Information
  1. All fees are ultimately the responsibility of the responsible party.

  1. By submitting this form, I hereby grant and understand that:

    • Permission is granted for review of medical records.
    • Permission granted to take pictures of patient for chart identification and educational purposes.
    • An associate RDHAP may be the provider of dental hygiene services.

Digital Signature