Orwick Dental Care

Acknowledgement of Receipt of Notice of Privacy Practices

You may refuse to sign this acknowledgement.

I have received a copy of this office's Notice of Privacy Practices.

Consent for Use and Disclosure of Health Information

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. You are entitled to a copy of this consent after you sign it. The original will be kept in your chart.

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. 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. You may obtain a copy of our notice of privacy practices, including any revisions of our notice, at any time by contacting: Orwick Dental Care, 7250 Main Street, Lanesville, Indiana 47136 (812) 952-1900.

Right to Revoke: You have the right to revoke this consent any time by giving us written notice submitted to the contact address above. Please understand that revocation of this consent will not affect any action we took in reliance of this consent before we received you revocation, and that we may decline to treat you or to continue treating you if you revoke this consent.

Consent: I have had full opportunity to read and consider the contents of this consent form and the notice of privacy practices for Orwick Dental Care, LLC. I understand that by signing this consent form, I am giving my consent for use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

     Individual refused to sign
     Communications barriers prohibited obtaining acknowledgement
     An emergency situation prevented us from obtaining acknowledgement
     Other (Please Specify)
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