Patient Consent Form – Onalaska and La Crosse Area Dentist

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used, but is not mandatory for me to sign in order to: Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly, obtain payment from third-party payers, conduct normal healthcare operations such as quality assessments and physician certifications. I have received a copy of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given a copy of your Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree than you are bound to abide by such restrictions.I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Name*
First Last
I authorize Valley Dental to disclose my dental information to the individuals listed below:
First Name Last Name Relationship
Signature*
Relationship to Patient:*
Date*
Date Format: MM slash DD slash YYYY

First Name	Last Name	Relationship