Consent Form Consent for Use and Disclosure of Health Information- HIPAASection A: Patient Giving ConsentName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Section B: To the Patient – Please Read the Following Statements CarefullyPurpose 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: 763-577-1375Right 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 - HIPAASignature*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 Reach Us 3475 Plymouth Blvd. Suite 200 Plymouth, MN 55447 Phone: 763-694-6158 / Fax: 763-577-1375 info@epicperio.com Map / Directions Forms New Patient Letter Patient Registration Medical History Dental History Consent Form Navigation Home Dr. Barss Dr. Jensen Services & Info Dental Professionals
