In order to provide you with optimum care, we draw upon the knowledge of our entire staff of doctors in consultation, diagnosis, and treatment of all patients. The undersigned hereby authorizes this dental office to perform the examinaion and alter explanation, the necessary dental services deemed appropriate for the care of the above name and furthermore will be responsible for the charges incurred from said dental patient.
SECTION B: PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY:
Purpose of Consent: By siginging this form you will consent to our use and disclosure of your protected health information to carry out treatmnet, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practicies before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.
We reserve the right to change our privacy practicies 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 ncahges. Those changes may aply to any of your protected health information that we maintain.
Your may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:
Contact Person: Sandra M. Petrocchi, D.D.S. Luis M. Arango, D.D.S
Telephone: (214) 363-9664 (214) 363-9902
Address: 8115 Preston Rd., Suite 130 8115 Preston Rd., Suite 130
Dallas, TX 75225 Dallas, TX 75225
Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in relaince to this consnet before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this consent.
I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand by signing this Consent fomr I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payments, and healthcare operations.
If this Consent is signed by a personal representative on behalf of the patient or parent, complete the follwing:
New Federal Regulations (HIPAA) requires that we maintain the privacy of your health information. We are required to provide you with the "NOTICE OF PRIVACY PRACTICES." It informs you of how we use and disclose health information about you for treatment, payment, and healthcare operations. You are asked to sign an “Acknowledgment of Receipt of Notice of Privacy Practices” and Consent for Use and Disclosure of Health Information.” You must also provide written “Authorization for several of our treatment management practices. Thank you for your cooperation in complying with the Federal HIPAA regulations. The privacy of your health information is important to us.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable Federal and State law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, your legal duties and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we requested or reviewed before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed on the first page of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose your health information about you for treatment, payment and healthcare operations. For example:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment to use your health information or to disclose it to anyone for any purposes. If you give us authorization you may revoke it in writing at anytime. Your revocation will not affect any use or disclosures permitted by your authorization white it was in effect. Unless you give us a written authorization we cannot use or disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of the Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved in Care: We may use or disclose health information to notify or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, location, general condition, or death. If you are present prior to use or disclosure of our incapacity or emergency circumstances we will disclose health information base on determination using our professional judgment and our experience with common practice to make reasonable inferences of our best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays or other similar forms of health information.
Marketing Health Related Services: We will not sure or disclose health information for marketing communications with our your written authorization.
Required By Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect : We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmates or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders, such as voicemail messages, postcards, or letters. This will require a written authorization.
School or Work Excuses: Will require a written authorization form or file.
Access: You have the right to review and receive copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format that you request unless we cannot practically do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed on the first page of the Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address on the first page of this Notice. If you request copies we will charge you $1.00 for each page $10 per hour of staff time to locate and copy your health information and postage if you want the copies mailed to you. If you request an alternative specified format, we will charge a cost-based fee for providing your health information in that format. If you prefer we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed on the first page of this Notice for a full explanation of our fee structure).
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities for the last 6 years, but not before April 12, 2003. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in emergency).
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means, or at alternative locations. You must make your request in writing, and it must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location requested.
Amendment: You have the right to request that we amend your health information. (Your request must be in writing and it must explain why the information should be amended). We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our Website or by electronic mail (email), you are entitled to receive this Notice in written form
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or you have questions or concerns, please contact us.
You may submit a complaint to us using the contact information on the first page of the Notice if: you are concerned that we may have violated your privacy rights; you disagree with a decision we made concerning access to your health information; our response to a request you made to amend or restrict the use or disclosure of your health information, or a request for us to communicate with you by alternative means or at alternative locations. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your health information.
REVOCATION OF CONSENT
I revoke my consent for your use and disclosure of my protected health information for treatment, payments activities, and healthcare operactions.
I understnad that revocation of my Consent will not affect any action you take in reliance on my Conesnet before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me ater I revoked my Consnet.