I understand as part of my health care, Piper Family Density originates and maintains paper and/or electronic records describing my health history, symptoms, examinations and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment

A means of communication among the health professionals who contribute to my care. 

A source of information for applying my diagnosis and treatment information to my bill

A means by which a third-party payer can verify that services billed were actually provided

A tool for routine health operations, such as assessing quality and reviewing the competence of staff.

I have been provided with a Notice of Patient Privacy Practices that provides a more complete description of information uses and disclosures.

I understand that I have the following rights and privileges:


The right to restrict or revoke the use or disclosure of my health information for other uses or purposes

The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations.

I further understand that Piper Family Dentistry reserves the right to change their notice and practices, in accordance with Section 164.520 of Code of Federal Regulations. Should Piper Family Dentistry change their notice, I may request a copy of any revised notice in person (or by U.S. mail, to be sent to the address I've provided).


I understand that as part of treatment, payment, or healthcare operation, it may become necessary to disclose or obtain health information to another entity, i.e., referral to other healthcare providers or previous providers. I consent to such disclosure for these uses as permitted by law.

I fully understand and accept the terms of this consent.

Please tell us with whom we may discuss your/patient's treatment, payment, or healthcare operation: Example: Spouse, children, or other relatives.


Please include names.