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Consent for use and
Disclosure of Health Information |
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Section A: Patient
Giving Consent |
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Patients
Name: _______________________________________ |
Social
Security # ______________________________________ |
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Section B: To the
Patient - Please Read the Following Statement |
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Purpose of
Consent: By signing this form, you will consent to our
use and disclosure of your protected Health Information to
carry our Treatment, Payment Activities and HealthCare
Operations. |
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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 disclosure we may make of your protected health
information, and of other important matters about the right
to change our privacy practices as described in our Notice
of Privacy Practices. A copy of our Notice of Privacy
Practices accompanies this Consent. 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. |
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I have had full
opportunity to read and consider the contents of this
Consent Form. I understand that, by signing this Consent
Form, I am giving my consent for your use and disclosure of
my Protected Health Information to carry out Treatment,
Payment Activities, and HealthCare Operations.
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I have
received a copy of this office's Notice of Privacy Practices
YES NO (Please circle one) |
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___________________________________________________________ |
__________________________ |
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Patient's
Signature |
Date
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___________________________________________________________ |
__________________________ |
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Personal
Representative's Signature |
Date |
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___________________________________________________________ |
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Personal
Representative's Relationship to Patient |
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________ We
attempted to obtain written acknowledgment of receipt of our
Notice of Privacy Practices, but acknowledgment could not be
obtained.
Reason:_______________________________________________________________________________________ |
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At any time
you have the right to revoke consent to disclose your
HealthCare information |
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Southeast Oral
Surgery
Maryville Office:
Phone 865-977-7110 Fax: 865-977-4132 /
Seymour Office: Phone 865-577-7800 Fax: 865-934-6989 |