The Office of Donald K Meyer, DDS
Information Posted @ WWW.CliffsideDental.com
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION


SECTION A: PATIENT GIVING CONSENT
Name:
Address:
EMail Address:
Patient #
Social Security #

SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By either printing and signing this form, or submitting this form electronically, you consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and health care 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 health care 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 is available here. 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. These changes will also be posted here. 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 on this website or by contacting:

Contact Person:Office Manager
Telephone Number:(816) 373-0753 -- Fax: (816)373-0792
EMail Address:OfficeManager@cliffsidedental.com
Postal Address:4731 Cochise, Suite 204, Independence, Mo. 64055

Right to Revoke: You have the right to revoke this Consent at any time by sending written notice of your revocation to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we have taken in reliance on this Consent before we received your revocation. Also, we may decline to treat you or to continue treating you, if you revoke this Consent.

SIGNATURE

I, __________________________________________________(printed) have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

Signature:_________________________________________________
Date: 

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative's Name:
Relationship to Patient:

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.

Include completed Consent in the patient's chart.