Bello-Burgos Smiles Tamiami Hipaa Consent Information Form

HIPAA – PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICIES

I acknowledge that I have been provided with TAMIAMI PARK DENTAL CENTER, “Notice of Privacy Practices”., and I am giving my consent for the use and disclosure of Protect Health Information as required and / or permitted by law.

Today's Date:

Patient Name:

Patient Signature:

Date:

EMAIL/TEXT MESSAGE TO MOBILE PHONE CONSENT FORM

Purpose: This form is used to obtain your consent to communicate with you by email/mobile text messaging regarding your Protected Health Information. TAMIAMI PARK DENTAL CENTER, (TDC) offers patients the opportunity to communicate by email/mobile text messaging. Transmitting patient information by email/mobile text messaging has a number of risks that patients should consider before granting consent to use email/mobile text messaging for these purposes. TDC will use reasonable means to protect the security and confidentiality of email/mobile text messaging information sent and received. However, TDC cannot guarantee the security and confidentiality of email/mobile text messaging communication and will not be liable for inadvertent disclosure of confidential information.

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with communication of email/mobile text messaging between TDC and I, and consent to the conditions outlined herein. Any questions I may have had were answered.

Patient Acknowledgment & Agreement

My Consented Email Address is:

My Consented Mobile Number For Text Messaging is:

Patient Signature:

Date: