HIPPA CONSENT FORM

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 to:

  •  Conduct, plan, and direct my child’s treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly (i.e., orthodontists or oral surgeons)

  • Obtain payment from your insurance company.

  • Conduct normal healthcare operations such as quality assessments and physician certifications.

  • Remind you of upcoming appointments, treatment options, or alternatives

ACKNOWLEDGMENT OF RECEIPT OF PRIVACY PRACTICES NOTICE

By checking the box below I acknowledge that I have received a Notice of Privacy Practices from the office of North Shore Dentistry for Children.

Parent/Guardian Signature

PHONE
(847) 869-5417
(847) 869-5509 FAX

LOCATION

One Rotary Center
1560 Sherman Avenue, Ste. 610
Evanston, Illinois 60201

HOURS

Mondays, Wednesdays & Thursdays:
7:30 AM — 5:00 PM
Tuesdays: 8:30 AM — 5:00 PM
Fridays: 7:30 AM — 2:00 PM

Saturdays : 8:30 AM — 3:00 PM

Copyright © 2020: All Rights Reserved: North Shore Dentistry for Children