Dental HIPAA consent form

Please fill in the details below.

I acknowledge that I have received and reviewed the dental office’s Notice of Privacy Practices. 

I understand that my dental records may include information about my medical history, diagnosis, and treatment. 

I authorize this dental practice to use and disclose my health information for: Treatment (providing, coordinating, or managing dental/medical care).

I authorize this dental practice to use and disclose my health information for: Payment (billing and collecting payment from insurance or other payers).

I authorize this dental practice to use and disclose my health information for: Healthcare operations (quality assessment, staff training, accreditation).

I understand that my information will not be shared with anyone outside the permitted purposes without my written authorization. 

Do you consent to voicemail/email reminders for appointments? 

Do you authorize sharing treatment information with your insurance provider? 

Do you authorize sharing information with other healthcare providers involved in your care? 

I understand that I have the right to: Access and request copies of my dental records.

I understand that I have the right to: Revoke this consent in writing at any time.