Consent For Use And Disclosure Of Health Information - The Rector Dental Group (Page 4 of 5) in pdf

THE RECTOR DENTAL GROUP

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Section A: PATIENT, PARENT OR LEGAL GUARDIAN GIVING CONSENT

Patients name:____________________________________________________________________

Address:_________________________________________________________________________

Telephone:_______________________________________________________________________

Section B: TO THE PATIENT, PARENT OR LEGAL GUARDIAN-PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.

Purpose of Consent: By signing this form, you will consent to our use and disclosure of you, or your child's protected

health information to carry our treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign

this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses

and disclosures we may make of your, or your child's protected health information, and of other important matters about

your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully

and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our

privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the change. Those changes may

apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

Contact Person: Dr. Rector

Telephone: 765-286-4017

Fax: 765-286-0372

Address: 3905 N Wheeling Ave., Muncie, IN 47304-1769

Rights to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation

submitted to the contact person listed above. Please understand that revocation of this Consent will not effect any action we

took in reliance on this Consent before we received your revocation, and that we decline to treat you or to continue treating

you if you revoke this Consent

SIGNATURE:

I, ________________________________________, have had full opportunity to read and consider the contents of this

Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form I am giving my consent

to your use and disclosure of my child's protected health information to carry our treatment, payment activities, and health

care operations.

Signature:____________________________________________________Date:_______________________________

If this Consent is signed by a personal representative on behalf of the patient, other than the parent, complete the following:

Personal Representative's name:______________________________________________________________________

Relationship to Patient:______________________________________________________________________________

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