Michael Ayzin, DDS
CONSENT FOR USE AND DISCLOSURE
OF HEALTH INFORMATION
SECTION A: PATIENT GIVING CONSENT
Name: ______________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Telephone: __________________________________________E-mail:___________________________________________
Patient #:___________________________________Social
Security #:___________________________________________
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: Crystal Reed
Telephone: 714 540-5511
Fax: 714 540-1733
E-mail: mayzin@aol.com
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 health 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.
Include completed Consent in the patient’s
chart.
REVOCATION OF CONSENT
I revoke my Consent for your use and disclosure of my
protected health information for treatment, payment
activities, and healthcare operations.
I understand that revocation of my Consent will not
affect any action you took in reliance on my Consent before you
received this written Notice of Revocation. I also
understand that you may decline to treat or to continue to treat
me
after I have revoked my Consent.
Signature: ___________________________________________________
Date: ___________________________________
© 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 (
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Last Modified: April 25, 2003