Consent For Use And Disclosure Of Health Information

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Adam N. Still, D.M.D., P.L.
CONSENT FOR USE AND DISCLOSURE
OF HEALTH INFORMATION
SECTION A: PATIENT GIVING CONSENT
Name: ______________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Telephone: __________________________________________E-mail:___________________________________________
Patient #:___________________________________Social Security #:___________________________________________
SECTION B: TO THE PATIENT — PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to
carry out 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 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 changes. Those
changes may apply to any of your protected health information that we maintain.
SECTION C: EMERGENCY CONTACT / OTHERS AUTHORIZED TO DISCUSS DENTAL RECORDS (HIPAA)
Name:_______________________________________________________ Phone#:______________________________
Relationship:___________________________________________
 Yes
 No
The person above is authorized to receive information regarding my dental records (Check one)
Name:_______________________________________________________ Phone#:______________________________
Relationship:___________________________________________
 Yes
 No
The person above is authorized to receive information regarding my dental records (Check one)
By listing the individual(s) above, you have given us permission to discuss your dental history and treatment with this person.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:
Contact Person:
Jaime Still
Telephone:
941-957-3311
Fax:941-957-3310
E-mail:
Address:
2389 Ringling Blvd., Suite C., Sarasota, FL 34237
Right 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 affect any action we
took in reliance on this Consent before we received your revocation, and that we may 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 protected health information to carry out treatment, payment activities and health care
operations.
Signature:__________________________________________________________Date: _____________________________
If this Consent is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative’s Name:__________________________________________________________________________
Relationship to Patient: _________________________________________________________________________________
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.
Include completed Consent in the patient’s chart.

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