SECTION B: TO THE PATIENT - PLEASE READ THESE STATEMENTS CAREFULLY
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.
COMMUNICATION: Smiles From the Hart Orthodontics reserves the right to communicate with the responsible party via text/e-mail regarding patient's treatment and finances. It is your responsibility to let us know if you would like to opt out of this feature.
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. A copy of our notice is available upon request with this consent. We encourage you to read it carefully and completely before signing this consent.
OFFICE PROCEDURES: As a part of your complimentary consultation our office will take x-rays and photographs of your teeth. This is for diagnostic purposes and will not be billed to you or your insurance company. It is near impossible for our doctors to give accurate treatment plans without these records.
USE OF RECORDS: Smiles From the Hart Orthodontics has the right to use patient photographs, x-rays, videos, and other photographic reproduction for the purpose of communication with your current and future dental and medical professionals. Our doctors also reserve the right for records obtained in our office to be used for professional, academic, patient education, and practice promotion. This includes, but is not limited to use on the Smiles From the Hart Orthodontics website, brochures, and social media sites.
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 make available upon request a revised Notice of Privacy Practices, which will contain the changes. 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 revision of our notice, at any time by contacting:
Telephone: 615-890-7246; 615-452-2868
Address: 1849 Memorial Blvd, Murfreesboro, TN 37129; 355 Hancock Street, Suite B, Gallatin, TN 37066
RIGHT TO REVOKE: You will have the right to revoke this consent at any time by giving us written notice or your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this consent.
SECTION C: SIGNATURE
I 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