Newberg Kids' Dentist Introduction (Page 4 of 6) in pdf

RESEARCH PARTICIPATION CONSENT FORM

Authorization for Use of Private Health Information

From time to time, we participate in research studies that look at past data on record.

This helps dentistry continue to make improvements in patient care. This form grants

permission given by you to use your and/or your child’s private health and dental

information located in Dr. Tim Richardson’s dental office for use in a research study.

This is a change by new federal law on medical record privacy.

Eugene Kids’ Dentist Notice of Privacy Practices Form: I have received the HIPAA

Notice of Privacy Practices.

1. Consent for Chart Review: I permit Dr. Richardson and collaborating educational

research teams to review my and/or my child’s dental record for possible research use

in chart review studies. This type of research only looks back at existing clinical records,

and does not involve any further contact with me. My identity and personal health

information will be kept confidential under the terms of the HIPAA Notice of Privacy

Practices that was provided to me.

2. Consent for Photos-External Use: I consent for any intraoral (inside the mouth)

clinical images and photographs for the purposes of external educational presentations

and research presentation and publications. I further consent that such

information/photography/images shall be the exclusive property of Dr. Richardson free

and clear of any claim on my part.

Voluntary Nature of this Consent

Your decision whether or not to consent will not affect your current or future relations

with your doctors or staff. If you decide to consent, you are free to withdraw at any time

without affecting those relationships. You must provide a written request to withdraw

from the consent for chart review and photos-external use.

BY SIGNING BELOW I ACKNOWLEDGE AND CONSENT TO ALL PARAGRAPHS

ABOVE.

_______________________________________

NAME OF PATIENT OR RESPONSIBLE PARTY

____________________________________________

_______________

__________

SIGNATURE OF PATIENT OR RESPONSIBLE PARTY

Legal Relationship

Date

Newberg Kids' Dentist Introduction Page 4