Authorization for Release of Protected Health Information s4

KENNETH M. LUBRITZ, D.D.S., INC.

Periodontics & Dental Implants

2500 Fondren, Suite 330

Houston, Texas 77063

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

Name______

Date of Birth______(for identification purposes only)

I hereby authorize Kenneth M. Lubritz, D.D.S., Inc. to release the following personal health information for: (Check all that apply by initialing)

_____ Dental service claims information and payment of claims

_____ Prescription, diagnostic, treatment, and/or care management services

_____ Reviews required by HHS or HIPPA-compliant health care operations

_____ Payment activities

_____ All of the above

The above information may be released by:

_____Phone ____Fax ____Mail ____Email ____Courier Service ____Hand Delivery

_____All of the above

MY CONSENT

Effective: Today’s Date______

I want this consent to: ___ Continue Indefinitely ___ Effective Only Until ___/___/____

I understand that consent may be revoked by me at any time in writing. I understand why I have been asked to disclose this information and am aware that my patient rights are identified in the practice’s Notice of Privacy Practices. I further understand that the transmission of PHI may not be secure when electronically transferred. I understand that that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by HIPPA Privacy regulations.

Signature of Patient______Date______

1 KENNETH M. LUBRITZ, D.D.S., INC.

Houston, Texas 77063 Or, Personal Representative______Date______

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

*You May Refuse to Sign This Acknowledgement*

I, ______, have received a copy of this Office’s Notice of Privacy Practices.

______

Please Print Name

______

Signature Date

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement count not be obtained because:

( ) Individual refused to sign

( ) Communications barriers prohibited obtaining the acknowledgement

( ) An emergency situation prevented us from obtaining acknowledgement

( ) Other (Please Specify)

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: PATIENT GIVING CONSENT

Name:______

Address:______

Telephone:______

Patient #______Social Security #______

SECTION B: TO THE PATIENT---PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

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, and healthcare operations.

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 the 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.

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 our Notice of Privacy Practices, including any revisions of our Notice, at any time contacting:

KENNETH M. LUBRITZ, D.D.S., INC.

Houston, Texas 77063 2500 Fondren Road, Suite 330

Tel: (713) 789-7676

Fax: (713) 789-7051

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 you 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.

Signature:______Date:______

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative’s Name:______

Relationship to Patient:______

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.