HIPAA AUTHORIZATION FORM

Street Address: _________________________________________________________________________________________________

(Permission from Pa�ent/Pa�ent’s legal guardian to share personal medical informa�on)

Date of Birth: ____________/______________/______________

Pa�ent Name: __________________________________________________________________________________________________

City, State, ZIP: _________________________________________________________________________________________________

I, _________________________________________________, hereby authorize JP Dental Har�ord and/or any other medical facility to release any and all medical informa�on and test results that pertain to me, to the following individual(s):

Name: __________________________ Phone #: (_______)________-___________ Rela�onship with the pt.______________________

Name: __________________________ Phone #: (_______)________-___________ Rela�onship with the pt.______________________

Name: __________________________ Phone #: (_______)________-___________ Rela�onship with the pt.______________________

I understand that I may revoke/cancel this authoriza�on by no�fying JP Dental Har�ord in wri�ng of my intent to revokethe authoriza�on or change the name(s) of the individuals to whom informa�on is to be released.

Signature of the Pa�ent ____________________________ Date _____________________________________

OR, if applicable-

Signature of legal guardian or personal rep of Pa�ent’s Estate ____________________________ Date _____________________________________

Descrip�on of authority to act for the pa�ent __________________________________________________________________________

Name of Witness____________________________ Date _________________ Witness Signature ________________________________

HIPAA Policy and Office Consents

We will use your Health Informa�on within our office to provide you with the best dental care possible. This may include administra�ve and clinical office procedures designed to op�mize scheduling and coordina�on of care between hygienist, dental assistant, den�st, and business office staff. In addi�on, we may share your health informa�on with physicians, referring den�sts, clinical and dental labs, pharmacies or other health care personnel providing you treatment. It also may be used:

TO OBTAIN PAYMENT We may include your health informa�on with an invoice used to collect payment for treatment you receive. We may do this with insurance forms filed for you in the mail or sent electronically. We will be sure to only work with the companies with similar commitment to the security of our health informa�on.

IN PATIENT REMINDERS Because we believe regular care is very important to your oral and general health, we will remind you of a scheduled appointment or that it is �me for you to contact us and make an appointment. Addi�onally, we may contact you to follow up on your care and inform you of treatment op�ons or services that may be of interest to you or your family. These communica�ons are an important part of our philosophy of partnering with our pa�ents to be sure they receive the best preven�ve and restora�ve care modern den�stry can provide. They may include postcards, le�ers, telephone reminders, email or tex�ng.

COPY OF RECORDS You are en�tled to a copy of your records from our office. You may be subject to a records produc�on fee of $0.75 per printed page, and $10 per printed page for xrays or other diagnos�c images. Please allow 7-10 business days for these records to be prepared and mailed. An emailed copy op�on is also available.

CONSENT FOR SERVICES and PHOTOGRAPHY

During the course of treatment, I may undergo procedures in all phases of den�stry including periodon�cs (gum treatment and surgery), oral surgery, endodon�cs (root canals), fixed and removable prosthodon�cs (crowns, bridges, and dentures), implant den�stry, restora�ve den�stry, temporomandibular disorder treatment, oral pathology, pediatric den�stry, and radiography.

No guarantees can be made about treatment outcomes, restora�on longevity, or prognoses. I understand that any branch of medicine, including den�stry, can involve unan�cipated results. JP Dental Har�ord will do everything possible to minimize unan�cipated or unintended outcomes.

ANESTHETICS: Most procedures are performed with a local anesthe�c (commonly referred to as Novocain and Zylocaine). In rare instances, allergic reac�ons may occur, so you are requested to inform our office staff of any known allergies you may have. Some seda�ve or pain medica�on may cause drowsiness. Therefore, when these medica�ons are used, you would need to make arrangements for transporta�on with another person.

PHOTOGRAPHY: Photos and video help us be�er see and explain dental condi�ons. I authorize the doctor and/or staff to take photographs and/or videos of me or dependent for for diagnosis, to understand and improve the outcome of my case, and/or for demonstra�on or marke�ng purpose on or offline through print publica�on or online media. My name will be kept confiden�al. I do not expect compensa�on, financial or otherwise, for use of these photographs. Check this box if you would only like to use photos/video for diagnosis and treatment only.

AUTHORIZATION AND RELEASE: I cer�fy that I have read and understood the above informa�on to the best of my knowledge. The above ques�ons have been accurately answered. I understand that providing incorrect informa�on can be dangerous to my health. I authorize the den�st to release any informa�on including the diagnosis and the records of any treatment or examina�on rendered to me or my child during the period of such dental care to third party payers and/or health prac��oners. I authorize and request my insurance company to pay directly to the den�st or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Patient/Parent/Guardian Signature Date

Name: __________________________________________________________________________________________________________________________