Martin S. Sugar, D.D.S., P.A.
25 Old Farm Lane
Shrewsbury, PA 17361
717.235.3837
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
This form is used for the use and release of information for purposes not granted in the H.I.P.A.A. Privacy Practices Notification. You do not need to fill-out this form unless requested to do so by our office.
(This form is optional)
Purpose: In cases where Dr. Martin S. Sugar has directed not to rely on Acknowledgements as a basis to use or disclose health information, this form is used to obtain a patient’s consent to our use and disclosure of the patient’s protected health information to carry out treatment, payment activities, and healthcare operations, as described more fully in our Notice of Privacy Practices.
SECTION A: PATIENT GIVING CONSENT
Name: ______________________________________________
Address: ____________________________________________
___________________________________________________
Telephone: _________________________ E-mail: ___________________________
Social Security Number: ___________________________
SECTION B: TO THE PATIENT—PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
Purpose of Consent:
By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices 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 of 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 practices 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 changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:
Contact Person: ______________________________________________________
Telephone: __________________________ Fax: _________________________
E-mail: _________________________________________
Address: _______________________________________________________________
_______________________________________________________________________
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 reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.
SIGNATURE
I, ______________________________________________, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and heath care operations.Signature: ___________________________________________ Date: ________________
If this Consent is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative’s Name: _____________________________________________
Relationship to Patient: ____________________________________
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.
© 2002 American Dental Association All Rights Reserved Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association. This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).