HIPAA Personal Health Info & Photo Release Form

THE HYGIENE HOUSE

Cathy Olander, RDHAP, BS LIC# HAP 1158 209-676-9375
-HIPAA/ Personal Health Information Waiver-
Date

MonthDayYear
Date
Name of Patient

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Information to be used or disclosed:

My dental information related to the following treatment/condition:____________________My dental records for the following date(s)_____________________________________Entire dental record with health history information related to drug/alcohol use.Other
Period of Allowed Health Records Disclosure

I am allowing the release of all dental and health records to THE HYGIENE HOUSE; Cathy Olander, RDHAP, BS until Oral health care preventative and therapeutic services are no longer needed.
Date From

MonthDayYear
Date
Date To

MonthDayYear
Date
Purpose of authorization

Treatment, payment or health care operationsTo the following family members___________________________________________________Other ______________________________________________________________________________
-Photo Release Consent Form-
I hereby authorize the release of photos and/or video images indicated herein. I consent to all dental images, photos and/or videos images taken of me are not limited to the date of service. I agree the photos and/or video images are used for the purposes of Oral health exam, diagnosis, treatment or consultation and will be forwarded to a referring DDS, Surgeon or Medical Physician by THE HYGIENE HOUSE; Cathy Olander, RDHAP, BS and becomes part of the patient's medical and dental record if needed.
I,_______________________________agree that the dental photos/images may be used by THE HYGIENE HOUSE; Cathy Olander, RDHAP, BS for Telehealth exam, diagnosis, treatment and/ or consultation with an existing DDS, Surgeon, or medical physician. By Signing this form, I acknowledge that I completely understand this consent form. I further acknowledge that there were no promises of compensation for such use of medical/dental photos and/or video images taken by THE HYGIENE HOUSE; Cathy Olander, RDHAP, BS as consented above.
Authorization of signature:

I authorize the release of my confidential protected dental information, as described in my directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions. The information that is used and/or disclosed pursuant to this authorization may be re-disclosed by the the recipient unless the recipient is covered by state laws that limit the use and/or disclosure of my confidential protected dental information
Patient is unable to sign

Patient is unable to sign
Reason
Please explain why patient is unable to sign this waiver
Name of Parent/Guardian/Custodial Care

First NameLast Name
Signature of the Patient :

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Signature of the Guardian/Custodial Care:

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Date

MonthDayYear
Date
Should be Empty:

THE HYGIENE HOUSE

-HIPAA/ Personal Health Information Waiver-

-Photo Release Consent Form-