HIPPA Form - Frank Batastini Orthodontics

HIPPA / Consent Form

Patient Giving Consent*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
To The Patient
Please Read the Following Statements Carefully
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.
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: Sherry Beatty Telephone: 856 262-0500 Fax: 856 262-1130 E-mail: FBortho@drfrankortho.com Address: 188 Fries Mill Rd., Turnersville, NJ 08012
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.
During you or your child’s treatment time here at Dr. Frank Batastini Orthodontics, there may be certain moments where photographs may be taken. These photos may be used on our website or in our offices for promotional use. We will never sell these photographs or provide them to a third party source. Please acknowledge below if you allow or do not allow consent for us to take photographs for promotional use.
Photograhy*
- Allow
- Do Not Allow
Please check your consent option
I Have Read...*
- I have read and acknowledge
By checking this box, I acknowledge that 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 checking this box on 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 heath care operations.
Name*
First Last
Entering your name constitutes a signature
Date*
If this Consent is signed by a personal representative on behalf of the patient, complete the following:
Personal Represntantive Name
First Last
Relationship to Patient

To The Patient