Notice of Privacy Practices Acknowledgement

I understand that, under the Health Insurance Portability & Accountability ACT of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information.  I understand that this information can and will be used for my treatment, payment of services I receive, healthcare operations of this practice, and as required by law.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information.  I have been given the right to review such Notice of Privacy Practices prior to signing this consent.  I understand that this office has the right to change its Notice of Privacy Practices from time to time and that I may contact this office at any time at 16 East Cedar Street, Three Forks, Montana to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations.  I also understand you are not required to agree to my requested restriction, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Authorization for Release of Information to Family (optional)

Many of our patients allow family members such as their spouse, parents or others to call and request dental or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your dental or billing information released to family members you must sign this form. Signing this form will only give information to family members indicated below.

I authorize Cornerstone Family Dental to release my medical and/or billing information to the following individual(s):