Omaha Orthodontics will assume the parent that brings the patient to our office is the custodial parent and we will release information regarding treatment progress to that parent at the appointment.
If another relative/adult brings the child to the appointment, we will assume that the custodial parent has given permission for that person to receive updates on treatment progress while the child is in our office.
Please authorize the release of Parent information to the following people by phone or in the child’s absence.
I acknowledge that I have received a copy of Omaha Orthodontics Notice of Privacy Practices on behalf of myself or my dependent:
I understand this notice explains how my protected health information is used and disclosed by the practice, and my rights regarding my protected health information.
I understand I should keep the Notice and refer to it if I have questions. I also understand I should contact the Compliance at compliance@sdbmail.com if I have a question or concern about my privacy rights.
DISCLAIMER: By typing your name below, you are giving your electronic signature. You agree that your electronic signature is the legal equivalent of your manual signature.