HIPAA Compliance Patient Consent Form


Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patients’ rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The Terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such revocation will not be retroactive.

By signing this form, I understand that:

  • Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
  • The practice reserves the right to change the privacy policy as allowed by law.
  • The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
  • The patient has the right to revoke this consent in writing at any time and all full disclosure will then cease.
  • The practice may condition receipt of treatment upon execution of this consent.

May we phone, email, or send a text to you to confirm appointments?  

May we leave a message on your answering machine at home or on your cell phone?

May we Discuss your medical condition with any members of your family?

If YES, please name the members allowed:

This Consent was signed by:

Patient Name(if not self):

Leave this empty:

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Carolina Dentistry @ The Stateline https://statelinedental.com
Signature Certificate
Document name: HIPAA Compliance Patient Consent Form
lock iconUnique Document ID: f939f0acd148e669ebf03deba223f553c751c467
Timestamp Audit
July 14, 2020 12:16 am EDTHIPAA Compliance Patient Consent Form Uploaded by Doctors Schwartz and Heidenreich - info@statelinedental.com IP 171.76.153.210
July 14, 2020 12:21 am EDTFront Desk - info@statelinedental.com added by Dr. Jim Schwartz - info@statelinedental.com as a CC'd Recipient Ip: 104.139.96.140
July 14, 2020 12:21 am EDTFront Desk - frontdesk.statelinedental@gmail.com added by Dr. Jim Schwartz - info@statelinedental.com as a CC'd Recipient Ip: 104.139.96.140