CLIFFORD V. ANDERSON,
Pediatric Dentist
PAMELA POGSON, DDS 523-7200
General Dentist
CONSENT FOR USE AND
DISCLOSURE OF HEALTH INFORMATON
Section A: PATIENT
GIVING CONSENT
Name:
_______________________________________________________
Address:
_____________________________________________________
Telephone:
___________________________________________________
Patient #:
____________________ Email: __________________________
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 heal
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 Officer: C.V. Anderson, D.D.S.
Telephone: 816-353-7200 FAX: 816-353-5162
Address: 4240 Blue Ridge Blvd #800,
Kansas City, MO. 64133
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 continue to treat me after I have revoked my Consent.
Signature: ______________________
Date: ________________________