HIPAA Consent Form

General Information

Name

Date of Birth

Street Address

City

State

Zip code

HIPAA Privacy Rights and Information Disclosure

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. These rights are more fully described in Downtown Dental’s Notice of Privacy Practices, updated effective January 1, 2023.

Under the requirements for HIPAA, your information will be used to:

Provide and coordinate my treatment among several health care providers who may be involved in that treatment directly and/or indirectly.
Obtain payment from third-party payers for my health care services.

If you wish to have your dental condition and/or dental treatment disclosed to someone else, please provide the below information.

Authorization

I AUTHORIZE Downtown Dental to disclose my information to the following recipients

I DO NOT AUTHORIZE Downtown Dental to disclose my information to the following recipients

Name of Person #1

Relationship to You

Purpose of Disclosure

Name of Person #2

Relationship to You

Purpose of Disclosure

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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