HIPAA Acknowledgment & Consent Form | Shelby Township Dentists

Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") requires that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future.

To comply with one of HIPAA'S requirements, we are giving you a copy of our Notice of Privacy Practices, upon your request. This Notice of Privacy Practices contain the following that HIPAA requires us to disclose regarding our privacy practice.

Existing Michigan Law requires (in addition to our attempt to obtain your written acknowledgement, discussed above) us to first obtain written consent prior to disclosing any of your Information except for our disclosures in connection with:
- A defense to a claim challenging our professional competence
- A review entity's functions
- A claim for payment of fees
- A third party payer's examination of our records
- A court order as part of a criminal Investigation
- An identification of a dead body
- A Iicensure investigation or child abuse/neglect investigation
From time to time it may be necessary for us to make disclosures of your information In connection with your treatment. For example, we may make a referral to or consult with another dentist or other health care professional. provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating your treatment.
Consent*
I consent to your disclosure of my information, which you deem are necessary in connection with my treatment. I understand that such disclosures may not be of the type listed above.
Patient Name*
First Last
Patient Signature*
Date*
MM slash DD slash YYYY

Patient HIPAA Acknowledgment & Consent Form