This message is being sent by or on behalf of a health care provider. It is intended exclusively for the individual or entity to which it is addressed. This communication may contain information that is proprietary, doctor-patient privileged, confidential or otherwise legally exempt from disclosure. If you are not the named addressee, you are not authorized to read, print, retain, copy or disseminate this message or any part of it. If you have received this message in error, please notify the sender immediately by telephone at 855-845-8415 or by reply transmission by e-mail, and delete all copies of the message
SECTION B TO THE PATIENT PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
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 accompanies this Consent. We encourage you to read it carefully and completely before signing this consent.
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, Healthcare Operations, Subpoenas, Immunization Information, Notice of Privacy Practices, Minnesota Healthcare Bill of Rights, Workers Compensation, Patient Access, Minors, Provider to Provider, Communication via email, text, USPS, Phone or Peripheral Vision company for email, questionnaires from the company authorized by Albany Family Dentistry.
PURPOSE OF ACKNOWLEDGEMENT: By signing this form you acknowledge you had the opportunity to read our Notice of Privacy Act for Albany Family Dentistry. 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 issue 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 Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting.
Contact Person: Albany Family Dentistry Address: PO BOX 609 Albany MN 56307
Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of 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 revoke this Consent.
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.
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT. INCLUDE COMPLETED CONSENT IN THE PATIENT’S CHART.
ACKNOWLEDGEMENT AND CONSENT FOR USE DISCLOSURE OF HEALTH INFORMATION