HIPAA

HIPAA

Joseph G. Vaughan D.D.S.
I have received a copy of the Notice of Privacy Practices of Joseph G. Vaughan. I hereby authorize, as indicated by my signature below, Joseph G. Vaughan to use and to disclose my protected health information for any necessary clinical, financial, and insurance purpose, as authorized in the Patient Consent form
Please check your preferred means of communication:
You may contact me at my home phone number

YesNo
My home phone number
You may contact me at my mobile phone number:

YesNo
My mobile phone number
You may contact me at my work phone number:

YesNo
My work phone number
You may send me a text message

YesNo
Phone Number
Please enter a valid phone number.
Please list authorized persons with whom we may discuss your Protected Health Information (PHI) in addition to custodial parents and legal guardians: (optional)
1. Name
2. Name
3. Name
I authorize the doctor to release any information, including the diagnosis and records of anytreatment or examination rendered, to third party and/or other health practitioners. I authorizemy insurance company to pay directly to the doctor unless otherwise payable to me and Iunderstand that my insurance carrier may pay less than the actual bill for services. I agree to beresponsible for payment of all services rendered on my behalf and dependents.
Patient signature

Clear
Guardian Signature (if minor):

Clear
Relationship to minor
Should be Empty: