5Ha%ieldLaneGoshenNY10924www.toothopiaden;stry.comPhoneNumber:(845)360-5883FaxNumber:(845) 360-5922 [email protected]
Patient HIPPA Form Withmypermission,ToothopiaPediatricDen;strymayusanddiscloseprotectedhealthinforma;on(PHI)aboutmetocarryouttreatment,paymentandhealthcareopera;ons(TPO).PleaserefertoToothopiaNo;ceofPrivacyPrac;cesforamorecompletedescrip;onofsuchusesanddisclosures.
IhavetherighttoreviewtheNo;ceofPrivacyPrac;cepriortosigningthisconsent.ToothopiaPediatricDen;stryreservestherighttoreviewitsNo;ceofPrivacyPrac;cesany;me.ArevisedNo;ceofPrivacyPrac;cesmaybeobtainedbyforwardingawriVenrequesttothePrivacyOfficer.
WithmypermissiontheofficeofToothopiaPediatricDen;strymaycallmyhomeorotherdesignatedloca;onsandleaveamessageonvoicemailorinpersoninreferencetoanyitemsthatassisttheprac;ceincarryingoutTPO,suchasappointmentremindercardsandpa;entstatementsaslongastheyaremarkedPersonalorConfiden;al.
WithmyPermission,theofficeofToothopiaPediatricDen;strymayE-mailto.Myhomeorotherdesignatedloca;onanyitemsthatassisttheprac;ceincarryingoutTPO,suchasappointmentremindercardsandpa;entstatements.IhavetherighttorequestthatToothopiaPediatricDen;stryrestrictshowitusesordisclosesmyPHItocarryoutTPO.However,theprac;ceisnotrequiredtoagreetomyrequestedrestric;ons,butifitdoes,itisboundbythisagreement.
Bysigningthis,IamallowingToothopiaPediatricDen;strytousanddisclosureofmyPHIforTPO.Imayrevokemyconsentinwri;ngexcepttotheextentthattheprac;cehasalreadymadedisclosuresinrelianceuponmypriorconsent.
Date:_____________________________
_______________________________ ________________________________SignatureofPa;entorLegalGuardian PrintnameofParent/LegalGuardian
