Form

HIPAA Notice of Privacy Practices

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

First Name

Last Name

Date Of Birth

Phone

SSN

Our doctor occasionally uses patient imaging and case materials for educational and promotional purposes, including use in coursework and web/print-based marketing. These materials are purged of any identifiable patient information. Please initial your choice below.

Please choose one option:

I have had the opportunity to read and consider the contents of your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent for the use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

* Right to revoke: you have the right to revoke this consent at any time by giving us written notice of your revocation. Please understand that revocation of this Consent will not affect in any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or continue treating you if you revoke this Consent *

Thank you,

Justin Shiflett, DDS

Patient/Legal Guardian Signature

Date