SECTION A: PATIENT GIVING CONSENT
Name:
Address:
Phone:
Email:
The
information provided above is for office use only.
SECTION B: TO THE PATIENT
PURPOSE OF
CONSENT: By signing this form you are giving your consent for this
office
To use
and disclose your protected health information to other dentists or healthcare
professionals as needed for referral purposes or medical information purposes
in order to carry out your treatment with the highest level of care
To handle
payment activities such as filing insurance claims, mailing of statements in
order to receive payment for services
To use
your information to further improve our services, procedures, continuing
education and further accreditations for both dentist and staff.
We
will be able to discuss your health information with family members if you are
unable to care for yourself or in an emergency.
We
will follow the law in releasing your information to federal or state
authorities in case of abuse, neglect or national security.
We
will notify you of your future appointments either by voicemail messages,
email, postcard or letters.
BY NO MEANS WILL YOUR
HEALTH INFORMATION BE RELEASED FOR MARKETING.
When
we use a photo of our patients in advertisements, a separate form will be signed
by that particular patient.
RIGHT TO REVOKE: You
have the right to revoke this Consent at any time by giving us written notice
of your revocation submitted to the Contact Person listed below. 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, I am giving my consent for
your use and disclosure of my protected health information to carry out
treatment, payment activities and healthcare operations.
If
this Consent is signed by a parent for their minor children or a personal
representative on behalf of an adult patient, please complete the following:
Name:
Relationsip
to Patient
You
may obtain a copy of our Notice of Privacy Practices, including any revisions
of our Notice, at any time by contacting:
Contact Person: Marijo Balderas
Telephone: 713-781-2800 Fax: 713-781-5641
Email: marijo@spikerdental.com
Address 1220 Augusta #200 Houston, Tx 77057
YOU
ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT
