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HIPAA Consent Form
IN THIS CONSENT FORM
Health Insurance Portability and Accountability Act (HIPAA)
This HIPAA Consent Form is entered into between Smile Science Dental Spa (“Provider”) and the patient (“Patient”), collectively referred to as the “Parties.”
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires health care providers to maintain the privacy of your personal health information and to provide patients with notice of their legal duties and privacy practices with respect to your personal health information.
ACKNOWLEDGEMENT OF PRIVACY PRACTICES
By signing this form, Patient acknowledges that Patient has received a copy of Provider’s Notice of Privacy Practices, which explains how Provider uses and discloses Patient’s personal health information.
VALID IDENTIFICATION AND HIPAA RELEASE FORM
In order to authorize the release of medical records to the Patient or any outside providers or facilities, the Patient shall be obligated to furnish a valid state or federally issued identification, which must not be expired, and shall also be required to execute a separate release form in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
CONSENT TO USE AND DISCLOSE HEALTH INFORMATION
- Patient Information: Patient consents to Provider using and disclosing Patient’s personal health information for the purposes of treatment, payment, and health care operations.
- Family/Friends: Patient consents to Provider disclosing Patient’s personal health information to a family member, friend, or other person as designated by Patient, as necessary to facilitate care or payment for care.
- Revocation: Patient understands that this consent may be revoked in writing at any time, except to the extent that Provider has already taken action relying on this consent.
AUTHORIZATION FOR OTHER USES AND DISCLOSURES
Provider will obtain Patient’s written authorization for uses and disclosures that are not identified by this consent form or permitted by applicable law.
RIGHTS UNDER HIPAA
Patient acknowledges that Patient has certain rights under HIPAA with respect to Patient’s personal health information, including the right to access and amend that information, request confidential communications, and request an accounting of certain disclosures.
COMPLAINTS
Patient may file a complaint with Provider or with the U.S. Department of Health and Human Services if Patient believes that Provider has violated Patient’s privacy rights. Patient acknowledges that Patient will not be retaliated against for filing a complaint.
QUESTIONS
Any questions regarding this Consent or Provider’s privacy practices can be directed to Provider’s privacy officer.
EFFECTIVE DATE AND CHANGES TO THIS CONSENT
This Consent is effective as of the date of signature and shall continue in effect until revoked in writing by Patient. Provider reserves the right to change this Consent and to make the new Consent provisions effective for all personal health information that Provider maintains.