patient hippa form to sign - toothopiadentistry.com · patient hippa form with my permission,...

5 Ha%ield Lane Goshen NY 10924 www.toothopiaden;stry.com Phone Number: (845) 360-5883 Fax Number: (845) 360-5922 [email protected] Patient HIPPA Form With my permission, Toothopia Pediatric Den;stry may us and disclose protected health informa;on (PHI) about me to carry out treatment, payment and healthcare opera;ons (TPO). Please refer to Toothopia No;ce of Privacy Prac;ces for a more complete descrip;on of such uses and disclosures. I have the right to review the No;ce of Privacy Prac;ce prior to signing this consent. Toothopia Pediatric Den;stry reserves the right to review its No;ce of Privacy Prac;ces any ;me. A revised No;ce of Privacy Prac;ces may be obtained by forwarding a wriVen request to the Privacy Officer. With my permission the office of Toothopia Pediatric Den;stry may call my home or other designated loca;ons and leave a message on voice mail or in person in reference to any items that assist the prac;ce in carrying out TPO, such as appointment reminder cards and pa;ent statements as long as they are marked Personal or Confiden;al. With my Permission, the office of Toothopia Pediatric Den;stry may E-mail to. My home or other designated loca;on any items that assist the prac;ce in carrying out TPO, such as appointment reminder cards and pa;ent statements. I have the right to request that Toothopia Pediatric Den;stry restricts how it uses or discloses my PHI to carry out TPO. However, the prac;ce is not required to agree to my requested restric;ons, but if it does, it is bound by this agreement. By signing this, I am allowing Toothopia Pediatric Den;stry to us and disclosure of my PHI for TPO. I may revoke my consent in wri;ng except to the extent that the prac;ce has already made disclosures in reliance upon my prior consent. Date:_____________________________ _______________________________ ________________________________ Signature of Pa;ent or Legal Guardian Print name of Parent/Legal Guardian

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Page 1: Patient HIPPA Form to sign - toothopiadentistry.com · Patient HIPPA Form With my permission, Toothopia Pediatric Denstry may us and disclose protected health informaon (PHI) about

5Ha%ieldLaneGoshenNY10924www.toothopiaden;stry.comPhoneNumber:(845)360-5883FaxNumber:(845) 360-5922 [email protected]

Patient HIPPA Form Withmypermission,ToothopiaPediatricDen;strymayusanddiscloseprotectedhealthinforma;on(PHI)aboutmetocarryouttreatment,paymentandhealthcareopera;ons(TPO).PleaserefertoToothopiaNo;ceofPrivacyPrac;cesforamorecompletedescrip;onofsuchusesanddisclosures.

IhavetherighttoreviewtheNo;ceofPrivacyPrac;cepriortosigningthisconsent.ToothopiaPediatricDen;stryreservestherighttoreviewitsNo;ceofPrivacyPrac;cesany;me.ArevisedNo;ceofPrivacyPrac;cesmaybeobtainedbyforwardingawriVenrequesttothePrivacyOfficer.

WithmypermissiontheofficeofToothopiaPediatricDen;strymaycallmyhomeorotherdesignatedloca;onsandleaveamessageonvoicemailorinpersoninreferencetoanyitemsthatassisttheprac;ceincarryingoutTPO,suchasappointmentremindercardsandpa;entstatementsaslongastheyaremarkedPersonalorConfiden;al.

WithmyPermission,theofficeofToothopiaPediatricDen;strymayE-mailto.Myhomeorotherdesignatedloca;onanyitemsthatassisttheprac;ceincarryingoutTPO,suchasappointmentremindercardsandpa;entstatements.IhavetherighttorequestthatToothopiaPediatricDen;stryrestrictshowitusesordisclosesmyPHItocarryoutTPO.However,theprac;ceisnotrequiredtoagreetomyrequestedrestric;ons,butifitdoes,itisboundbythisagreement.

Bysigningthis,IamallowingToothopiaPediatricDen;strytousanddisclosureofmyPHIforTPO.Imayrevokemyconsentinwri;ngexcepttotheextentthattheprac;cehasalreadymadedisclosuresinrelianceuponmypriorconsent.

Date:_____________________________

_______________________________ ________________________________SignatureofPa;entorLegalGuardian PrintnameofParent/LegalGuardian

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