HIPAA Statement
HIPAA Notification and Consent to Treat a Minor
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that my signing this consent, I authorize you to use and disclose my protected health information to carry out:
Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
Obtaining payment from third-party payers (e.g. my insurance company)
The day-to-day healthcare operation of our practice
I have also been informed of and given the right to review and secure a copy of our Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.
I understand that I have the right to request restriction on how my protected health information is used and disclosed to carry out treatment, payment and healthcare operations, but hat you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.
I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
Permission to Treat
Since ________________________________ is a minor, it becomes necessary that signed permission be obtained from the parent or guardian before any and all necessary dental services can be performed by Snodgrass-King Pediatric Dental Associates, P. C. I, being the parent or guardian of the above minor patient, do authorize and request the performance of dental services for this patient; and the performance of whatever procedures Snodgrass-King Pediatric Dental Associates, P. C. may deem necessary during the performance of any procedures. Furthermore, I will be responsible financially for any bill incurred for this patient for dental treatment; including any attorney or court fees in the even it becomes necessary to place this account in collectibles.
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Signed/Relationship
