Smile NY Consesnt Form

Revised 8/02/17 KEEP FOR YOUR RECORDS Revised 1/23/2017 ELLIOT P. SCHLANG, DDS - GENERAL DENTIST, DENTAL DIRECTOR NYC Department of Education Oral Health Clinic Program School Parental Consent Form Angelina Adames, DDS, Jungmin Cho, DMD, Jennifer Corredor, DDS, Sylvia Cuellar, DDS, Joseph D’Ambrosio, DMD, Jason Davis, DDS, Christopher Dillon, DDS, Andrew Fradkin, DDS, Margaret Garland, DDS, Renee Gaska, DMD, Page 1 of 2 Jeffrey Gershon, DMD, Daria Grillo, DDS, Barry Hecht, DMD, Deborah Kahn, DMD, Sahar Kamkar, DMD, Aditi Kapoor, DMD, Uzma Khan, DDS, Jeffrey Krantz, DDS, Stephen Marshall, DDS, Deena Pegler, DMD, Alan Poritzky, DDS, SMILE NEW YORK OUTREACH, LLC* Melissa Rodgers, DMD, Deniz Salierno, DDS, Elliot Schlang, DDS, Karimeh Shehadeh, DDS, Jeffrey Tenenbaum, DDS, Nancy Yu, DDS 37-30 Review Ave., Suite 102, Long Island City, NY 11101 Phone: 855-469-7473 Fax: 888-330-4331 NOTICENOTICE OF OF PRIVACY PRIVACY PRACTICES PRACTICES STUDENT INFORMATION PARENT/GUARDIAN INFORMATION THISTHIS NOTICE NOTICE DESCRIBES DESCRIBES HOW MEDICAL HOW MEDICAL INFORMATION INFORMATION ABOUT YOU ABOUT MAY YOU BE USED MAY ANDBE USED DISCLOSED AND DISCLOSED AND HOW YOU AND CAN HOW GET YOU ACCESS CAN GETTO THIS ACCESS INFORMATION. TO THIS PLEASE REVIEW IT CAREFULLY. KEEP FOR YOUR RECORDS INFORMATION. PLEASE REVIEW IT CAREFULLY. KEEP FOR YOUR RECORDS Student’s Last Name: _________________________________ OUR LEGAL DUTY Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as Mother The privacyOUR ofLEGAL your medical DUTY information is important to us. We are required by applicable federal and state law to voicemail messages, postcards, letters, emails or text messages). Student’s First Name: _________________________________ Last Name: __________________First Name: _____________ maintainThe the privacy privacy ofof your your health medical information. information We are also is requiredimportant to give to youus. this We Notice are about required our privacy by applicable practices, federal and state law to maintain the privacy of your health information. We are also required our legal duties, and your rights concern¬ing your health information. We must follow the privacy practices that are Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. : __________/__________/____________ describedour legalto give duties, in this you andNotice this your whileNotice rights it is concern¬ing aboutin effect. our We your privacywill healthnotify practices,you information. if your unsecured ourWe mustlegal medicalfollow duties, the information privacy and your practices is breached. rights that concern¬ingare These your oversight health activities information. include, for example, We mustaudits, investigations, follow the inspections privacy andpractices licensure surveys.that are These described activities are in necessary this for Date of Birth Father describedNotice in this while Notice it iswhile in effect.it is in effect. We Wewill will notify notify you you ifif your your unsecured unsecured medical medical information information is breached. is breached.These oversight activities include, for example, audits, investigations, inspections and licensure surveys. These activities are necessary for the government to monitor the health care system, the outbreak of disease, government programs, compliance with civil rights laws Month Day Year Last Name: _________________ First Name: _____________ We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such and to improve patient outcomes. changesWe arereserve permitted the by right applicable to change law. We ourreserve privacy the right practices to make the and changes the terms in our privacy of this practices Notice at any time, provided such changes are permitted by applicable law. We reserve the right School________________________________ Grade________ and theto makenew terms the of changesour Notice effectivein our forprivacy all health practices information and that wethe maintain, new terms including of ourhealth Notice information effective Lawsuits for all health and Disputes: information We may disclose that we health maintain, information including about you in responsehealth informationto a court or administrative we created order. Weor may we createdreceived or received before before we madewe made the the changes. changes. Before Before we makewe make a significant a significant change in changeour privacy in our privacyalso disclose practices, health information we will about change you in response this Notice to a subpoena, and discoverymake the request new or other Notice lawful available process. upon Legal Guardian, If Applicable practices,request. we will change this Notice and make the new Notice available upon request. Other Uses and Disclosures. As permitted or required by law, we may use or disclose your medical information for research Teacher’s Name:_____________________________________ Last Name: __________________First Name: _____________ You may request a copy of our Notice at any time. For more information about our privacy practices, or for purposes; to organizations that handle and monitor organ donation and transplantation; for workers’ compensation or similar additionalYou copiesmay requestof this Notice, a copy please of contact our Notice us using at the any information time. For listed more at the information end of this Notice. about our privacyprograms practices, to comply with or laws for related additional to workers’ copies compensation of this or similar Notice, programs please that provide contact benefits us for using work-related the injuries Relationship of legal guardian to student additionalinformation copies of listedthis Notice, at the please end contact of this us Notice.using the information listed at the end of this Notice. programs to comply with laws related to workers’ compensation or similar programs that provide benefits for work-related injuries or illness; for public health activities such as to prevent or control disease, injury or disability; to report reactions to medications or Student’s Social Security Number: _____________________ USES AND DISCLOSURES OF HEALTH INFORMATION problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed Grandparent Aunt or Uncle Other: _______________ We useUSES and discloseAND DISCLOSURES health information OF about HEALTH you for treatment, INFORMATION payment, and healthcare operations. problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed (Optional, but helpful) ForWe useexample: and disclose health information about you for treatment, payment, and healthcare operations. to, or is at risk for contracting or spreading a disease; to medical examiners to identify a deceased person or determine cause of For example:We use and disclose health information about you for treatment, payment, and death;healthcare or to funeral operations. directors to carry outFor their example: duties. Sex: Male Female Treatment: We may use or disclose your health information to a physician, school nurse, or other healthcare Contact Information for parent or guardian Treatment:Treatment: We may We use ormay disclose use youror disclose health information your health to a physician, information school tonurse, a physician, or other healthcare school nurse,PATIENT or RIGHTSother healthcare provider providing treatment to you. provider providing treatment to you. Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in : Hispanic Black White American Indian Payment:Payment: We may We use mayand disclose use and your disclose health information your health to obtain information payment for servicesto obtain we paymentprovide to you. for serviceswriting we to obtain provide access to to you. your health information and fax your request to the number at the end of this Notice. Ethnicity Home Tel: ________________Work Tel: __________________ Payment: We may use and disclose your health information to obtain payment for services we provide to you. Asian/Pacific Islander Other _____________ Healthcare Operations: We may use and disclose your health information in connection with our business Disclosure Accounting: You have the right to receive a list of some disclosures we or our business associates have made of your Cell: _______________________________________________ HealthcareHealthcare Operations: Operations: We may use We and maydisclose use your and health disclose information your in connectionhealth information with our business in connection health withinformation. our Ifbusiness you request thisoperations accounting more such than as once reviewing in a 12-month the period, competence we may charge oryou qualifications a reasonable, cost- operationsof healthcare such as reviewing professionals the competence and evaluating or qualifications practitioner of healthcare and professionals provider and performance. evaluating based fee for responding to these additional requests. practitioner and provider performance. based fee for responding to these additional requests. Student Address:____________________________________

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