Acknowledgement of Receipt of Notice of Privacy Practices and Treatment 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 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

• Treatment (including discussing my treatment options and images with other medical/dental providers)

• Obtaining benefit information and payment from third party payers (e.g. my insurance company)

• The day-to-day operations of your practice

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 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 contact you at any time to obtain the most current copy of this notice. 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 is not affected.

I also consent to the treatment provided today by Dr. Elliott and/or his employees.
Patient First Name:
Last Name:
Birthdate:

The following names are people whom I give permission for Elliott Orthodontics to share the above-named patient’s protected health information with:
Name:
Relationship to Patient:
Name:
Relationship to Patient:
Name:
Relationship to Patient:
Name:
Relationship to Patient:
(Must be signed by Parent or Guardian if patient is under 18.)
Patient/Parent/Guardian E-Signature:
Relationship to Patient:
Date: