CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION AND MEDIA RELEASE

Date:
Patient First Name:
Patient Last Name:
Responsible Party First Name:
Responsible Party Last Name:
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 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 is available upon request.

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.

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. Parent’s approval by signature if patient is less than 18 years of Age. You are entitled to a copy of the consent after you sign it.
Responsible Party/Patient Signature
Date:
Media Release
I, the undersigned, do hereby consent and agree that TC Orthodontics, its employees, or its agents have the right to use photographs, artwork, designs, videotape, or digital recordings of me and to use these in any and all print/media/social media, now or hereafter known, and exclusively for the purposes of education and promotion. I further consent that my name and identity may be revealed therein or by descriptive text or commentary.

I do hereby release to TC Orthodontics and its agents and employees all rights to exhibit this work in print and electronic form publicly or privately. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used. I understand that there will be no financial or other remuneration for recording me, using my likeness or my story, either for initial or subsequent transmission, playback, print, or electronic/social media.
Please indicate by checking Yes or No that you accept the terms of this Media Release.
PATIENT COMMUNCATION FORM
A. Family and Friends: It is the office policy of TC Orthodontics not to release confidential medical information regarding your treatment to family member or friends, except for (i) parent/legal guardian, (ii) other persons authorized by the patient, (iii) as we may reasonably infer from the circumstances (for example, if you bring a family member or friend into the exam , we will assume, unless you object, that the personal is entitled to receive information regarding your treatment, (iv) in emergency situations, or (v) as otherwise permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

If you anticipate that you will need or want your medical information to be provided to family members, friends, or caretakers/babysitters, please indicate that below, so that we may best serve you. If you do not want any of your medical information provided to a family member, please circle the “no” response. By signing below, you authorize the following people to receive information regarding your treatment or care. (If you wish to add names later, please confirm this in writing, or call our staff.)

You may cancel this authorization to the extent allowed by law. If you do, you understand that the doctor or practice may have already released information about you after you gave permission. You understand that cancelling this authorization would not prohibit any release of information by the practice in reliance on your original authorization.

If you wish to cancel or change this agreement, please call TC Orthodontics or issue a letter in writing.
Spouse:
Health Care Information:
Financial Information:
Parent:
Health Care Information:
Financial Information:
Other:
Health Care Information:
Financial Information:
Other:
Health Care Information:
Financial Information:
B. Alternative Communications: You are also entitled to specify alternative, reasonable means of communication, if you do not wish to be contacted by us in a certain way.
I hereby request the following means of contact only:
PRINTED NAME:
Patient/Parent/Guardian Signature:
Date: