Patient Privacy Consent

This form is required by the patient privacy regulations issued by the United States Department of Health and Human Services. Prior to commencing your orthodontic treatment, you must review, sign and date this form.
Your protected health information may be used in connection with your treatment, payment of your account or health care operations. Educational purposes including lectures, presentations and case studies. Your protected health information including names and dates will NOT be disclosed. This information will be disclosed only to dental professionals.
The information used or disclosed per this authorization may be subject to redisclosure by the recipient(s), and thus, no longer protected by the privacy rules.
We will maintain a good faith effort to protect your privacy as stated on our privacy notice. You have a right to review our policy before signing this consent.
This consent authorizes us to treat the patient, release information as needed to treat the patient and release information to seek payment for treatment.
You have a right to request restrictions or revoke use of your protected health information at any time with a written request.
Patient First Name:
Last Name:
Responsible Party's First Name:
Responsible Party's Last Name:
Signature (Responsible Party, if patient is a minor):
Relationship To Patient: