Patient Forms | Pine Ridge Dental

HIPPA Privacy Consent

"*" indicates required fields

SECTION A: PATIENT GIVING CONSENT

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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 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 accompanies this Consent. 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 of our Notice, at any time by contacting:
Contact Person: Dr. Jenny Telephone: 763-856-5100
Fax: 763-856-0366 Address: 26273 2nd
Street E., Suite A P.O. Box 448, Zimmerman, MN 55398

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your 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.

Date*

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

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.
Include completed Consent in the patient’s chart.

I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations. I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent regardless of your dental status.

Digital Signature*

Date*

CAPTCHA

HAVE A QUESTION?

Give our knowledgable staff a call today!

Whether it’s a question about our dental services or to schedule an appointment, Pine Ridge Dental is here to help. Give us a call at 763-856-5100 or visit us at 26273 2nd Street E , Suite A, Zimmerman, MN 55398.