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16Harmony Family Dental
Harmony Family Dental
10103 N. DIVISION SUITE 201
SPOKANE, WA 99218
509-467-1562
HIPAA Patient Consent Form
I understand that I have certain rights to privacy regarding my protected health information. These rights
are given to me under the Health Insurance Portability and Accountability Act of 1996 (a.k.a. HIPAA or The
Healthcare Privacy Act). I understand that by signing this consent, I authorize Harmony Family Dental to
use and/or disclose my protected health information to carry out the following:
Treatment which includes direct and/or indirect treatment by other healthcare providers involved in
my treatment.
Obtaining payment from third party payers, i.e. my dental and/or medical insurance
company/companies.
The day to day healthcare operations of your dental practice.
Additionally, I authorize you to share all my protected health information with the following individual(s):
Name:
Relationship:
Phone:
-
-
Name:
Relationship:
Phone:
-
-
Name:
Relationship:
Phone:
-
-
I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy
Practices, which contains a more complete description of the uses and disclosures of my protected
personal health information, and my rights under HIPAA. I understand that you reserve the right to change
the terms of this notice from time to time and that I may request the most current copy of this notice. I
understand that I have the right to request restrictions on how my protected health information is used and
disclosed to carry out treatment, payment and healthcare operations, but that you are not required to agree
to use these requested restrictions. However, if you do agree, you are then bound to comply with this
restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or
disclosure that occurred prior to the date I revoke this consent will not be affected.
Signature (Type your name to sign electronically, or print and sign):
Date (mm/dd/yyyy):
/
/
01
01
2017
If signing on behalf of someone, explain your relationship to the patient:
02
02
2018
03
03
2019
For Office Use Only
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04
2020
Patient refused or was unable to sign. Good faith effort was made to obtain acknowledgement of receipt.
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05
2021
The following circumstances prohibited the patient from signing the consent form:
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2022
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2023
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08
2024
Describe your good faith effort to obtain the individual's signature on this form:
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09
2025
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10
2026
Office Personnel Signature:
Office Personnel Name:
Office Personnel Title:
Date:
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11
2027
/
/
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01
2017
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02
02
2018
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03
03
2019
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04
2020
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2021
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2022
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