PATIENT CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: PATIENT GIVING CONSENT:

First Name:

Last Name:

Date of Birth:

SECTION B: TO THE PATIENT- PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.

Notice of Privacy Practices: Our notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right (and we strongly encourage you) to review our notice before signing. The terms of our notice may change. You may obtain the Notice of Privacy Practices at any time by contacting our office, including revisions.

Purpose of Consent: By signing this form, you are giving consent to use and disclose (PHI) Protected Health information to carry out your treatment, payment activities and health care operations. You have the right to make restrictions or revoke this consent at anytime in writing. However, such restrictions or revocation shall not affect any disclosures we have already made in reliance on your prior consent.

We obtain the right to decline treatment or to continue to treat you if you revoke this consent. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Patient Signature:

Date:

If you are a patient over the age of 18, but on your parent/ legal guardians insurance, please initial & date here to give us permission to speak to them regarding your billing information:

Signature of Person Representing the patient on their behalf:

Relationship to the patient:
Signed in front of NVOS Staff Personnel:

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I Hereby acknowledge that I have received and reviewed or have been given the opportunity to receive and review a copy of Northern Vermont Oral Surgery’s Notice of Privacy Practices.

Signature of Patient or Authorized Representative:

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT