HIPAA compliance Form For Houston Heights Dentistry

We cannot discuss or disclose any HIPPA protected information with anyone that is not you. If you would like us to be able to talk with anyone other than yourself about your health care or finances, we need this consent on record.

I give my permission for Houston Heights Dentistry to give and receive information about my care and account to:*

I give my permission for Houston Heights Dentistry to give and receive information about my care and account to:

Name

Relationship

I do not give my permission for Eglash Dental Studio to give information about my care to anyone.*

I do not give my permission for Houston Heights Dentistry to give information about my care to anyone.

This consent will stay in effect for 1 year or until further notice.

Patient Name*

Patient Signature*