River Ridge Orthodontics HIPAA Consent Form

Patient First Name:
Last Name:

The department of Health and Human Services has established a “Privacy Rule" to help ensure that personal health care/dental care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain heath care/dental care providers to obtain their patient’s consent for uses and disclosures of heath/dental information about the patient to carry out treatment, payment or health care/dental care operations.

As our patient we want you to know that we respect the privacy of your personal medical/dental records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health/dental information and information about treatment, payment or health care/dental care operations, in order to provide health care/dental care that is in your best interest.

We also want you to know that we support your full access to your personal heath/dental (orthodontic) records. We may have indirect treatment relationships with you (such as laboratories that only interact with dentists and not patients), and may have to disclose personal dental information for purposes of treatment, payment or dental care operations. The entities are most often not required to obtain patient consent.

Under federal law, title 42, Part 2, rules of the Code of Federal Regulations provide heightened confidentiality protections for records related to federally assisted substance use disorder diagnosis, treatment, or referral. Some information, such as HIV-related information, genetic information, alcohol and/or substance use disorder treatment records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records. In no event will we use or disclose your Part 2 Program record, or testimony that describes the information contained in your Part 2 Program record, in any civil, criminal, administrative, or legislative proceedings by any Federal, State, or local authority, against you, unless authorized by your consent or the order of a court after it provides you notice of the court order.

You may refuse to consent to the use or disclosure of your personal health/dental information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent.

If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer.

You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.

Patient/Parent/Guardian E-Signature:
Date:

Compliance Assurance Notification for Our Patients

To Our Valued Customers:

The misuse of Personal Health Information (PHI) has been identified as a national problem causing patients inconvenience, aggravation and money. We want you to know that all of our employees, managers and doctors continually undergo training so that they may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the Privacy Rule. We strive to achieve the very highest standards of ethics and integrity in performing services for our patients.

It is our policy to properly determine appropriate use of PHI in accordance with the governmental rules, laws and regulations. We want to ensure that our practice never contributes in any way to the growing problem of improper disclosure of PHI. As part of this plan, we have implemented a Compliance Program that we believe will help us prevent any inappropriate use of PHI.

We also know that we are not perfect! Because of this fact, our policy is to listen to our employees and our patients without any thought of penalization if they feel an event in any way compromises our policy of integrity. More so, we welcome your input regarding any service problem so that we may remedy the situation promptly.

Thank you for being one of our highly valued patients,

Dr. Daniel Garrison, DMD, ABO