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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.

Thanks for submitting!