Name: EPIC: Exceptional Periodontal and Implant Concepts
Address: 3475 Plymouth Blvd. Suite 200, Plymouth, Minnesota, 55447, US
Price range: $$$

HIPPA Consent Form

Consent for Use and Disclosure of Health Information- HIPAA
Section A: Patient Giving Consent
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
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 (HIPAA) 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 is posted in our office and is also available upon request. 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 by contacting: Contact Person: Dr. Jeanne Barss Phone: 763-694-6158 Fax: 763-577-1375
Right to revoke: You will have the right to revoke this Consent at any time by giving us written notice of you 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.
I,*
First Last
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.
Consent*
I consent for Use and Disclosure of Health Information - HIPAA
Signature*
Date*
MM
DD
YYYY
If this Consent is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative's Name
First Last
Relationship to Patient
Consent
I understand that the information on the Registration, Medical History, and Dental History forms are necessary to provide dental care in a safe and efficient manner. I have answered the questions to the best of my knowledge. Should further information be needed, the staff of Jeanne L. Barss DDS, MS, PA has permission to ask the respective Health/Dental care provider to release such information. I will notify this office of any changes in my health or medications. If payment for services rendered is not made in a timely manner, your account may be turned over to an outside collection agency and you will be responsible for collection fees. A $25 fee will be charged for insufficient funds on returned checks. A late (less than 48 hours) cancellation fee of 10% of your surgery amount may apply. The late (less than 48 hours) fee for cancelled maintenance appointments is $50. I understand that I am financially responsible for all charges regardless of insurance coverage.