Newberg Kids' Dentist Introduction (Page 3 of 6) in pdf

Newberg Kids' Dentist Introduction Page 3

Receipt o f P rivacy P ractices & C onsent f or U se a nd D isclosure o f

Health I nformation

Acknowledgement o f R eceipt o f N otice o f P rivacy P ractices:

I, _ _________________________________________________, h ave r eceived a c opy o f t his o ffice’s N otice o f P rivacy P ractices

pertaining t o m y c hild, _ ___________________________________________.

Parent/Guardian S ignature: _ _______________________________________ D ate: _ ________________

Parent/Guardian G iving C onsent

To t he P arent/Guardian,

Please r ead t he f ollowing s tatements c arefully.

Purpose o f C onsent: B y s igning t his f orm, y ou w ill c onsent t o o ur u se a nd d isclosure o f p rotected h ealth i nformation t o c arry

out t reatment, p ayment a ctivities a nd h ealthcare o perations. Y ou m ay r evoke y our c onsent a t a ny t ime. F ailure t o p rovide

consent m ay r esult i n o ur o ffice n ot b eing a ble t o p rovide c are f or y our c hild.

We r eserve t he r ight t o c hange o ur p rivacy p ractices a s d escribed i n o ur N otice o f P rivacy P ractices. I f w e c hange o ur p rivacy

practices, w e w ill i ssue a r evised N otice o f P rivacy P ractices, w hich w ill c ontain t he c hanges. T hose c hanges m ay a pply t o a ny o f

your p rotected h ealth i nformation t hat w e m aintain.

Parent/Guardian S ignature: _ ____________________________________________ D ate: _ ___________

Address: _ ____________________________________________ P hone # : _ _______________________

Newberg Kids' Dentist Introduction Page 3