CONSENT TO USE OR DISCLOSE INFORMATION FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS
The patient hereby consents to the use or disclosure of his/her individually identifiable health information (“protected health information”) by Wake Dental Wellness in order to carry out treatment, payment, or health care operations. the patient has reviewed this Office’s Notice of Privacy Practices for Protected Health Inofmraiotn for a more complete description of the potential uses and disclosures of such information and has the right to review such Notice prior to signing this consent form.
This Office reserves for itself the right to change the terms of its Notice of Privacy Practices for Protected Health Information at any time. If this Office does change the terms of its Notice of Privacy Practices, I may obtain a copy of the revised notice by contacting the Office.
The patient retains the right to request that this Office further restrict how the Patient’s protected health information is used or disclosed to carry out treatment, payment, or health care operations. This Office is not required to agree to such requested restrictions; however, if this Office does agree to my requested restriction(s), such restrictions are then biding on Office.
At all times, the Patient retains the right to revoke this consent. Such revocation must be submitted to this Office in writing. The revocation shall be effective except to the extent that this Office has already taken action in reliance on the Consent.
This Office may refuse to treat the Patient if he/she (or an authorized representative) does not sign this Consent Form (except to the extent that this Office is required by law to treat individuals). If the Patient (or authorized representative) signs this Consent Form and then revokes consent, this Office has the right to refuse to provide further treatment to the Patient as of the time of revocation (except to the extent that this Office is required by law to treat individuals).
I HAVE READ AND UNDERSTAND THIS INFORMATION. I HAVE RECEIVED A OCPY OF THIS FORM AND I AM THE PATIENT OR AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS DOCUMENT VERIFYING CONSENT TO THE ABOVE-STATED TERMS.
