<p> KENNETH M. LUBRITZ, D.D.S., INC.</p><p>Periodontics & Dental Implants</p><p>2500 Fondren, Suite 330</p><p>Houston, Texas 77063</p><p>AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION</p><p>Name______</p><p>Date of Birth______(for identification purposes only)</p><p>I hereby authorize Kenneth M. Lubritz, D.D.S., Inc. to release the following personal health information for: (Check all that apply by initialing)</p><p>_____ Dental service claims information and payment of claims</p><p>_____ Prescription, diagnostic, treatment, and/or care management services</p><p>_____ Reviews required by HHS or HIPPA-compliant health care operations</p><p>_____ Payment activities</p><p>_____ All of the above</p><p>The above information may be released by:</p><p>_____Phone ____Fax ____Mail ____Email ____Courier Service ____Hand Delivery</p><p>_____All of the above</p><p>MY CONSENT</p><p>Effective: Today’s Date______</p><p>I want this consent to: ___ Continue Indefinitely ___ Effective Only Until ___/___/____</p><p>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. </p><p>Signature of Patient______Date______</p><p>1 KENNETH M. LUBRITZ, D.D.S., INC.</p><p>Periodontics & Dental Implants</p><p>2500 Fondren, Suite 330</p><p>Houston, Texas 77063 Or, Personal Representative______Date______</p><p>ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES</p><p>*You May Refuse to Sign This Acknowledgement*</p><p>I, ______, have received a copy of this Office’s Notice of Privacy Practices.</p><p>______</p><p>Please Print Name</p><p>______</p><p>Signature Date</p><p>2 KENNETH M. LUBRITZ, D.D.S., INC.</p><p>Periodontics & Dental Implants</p><p>2500 Fondren, Suite 330</p><p>Houston, Texas 77063</p><p>For Office Use Only</p><p>We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement count not be obtained because:</p><p>( ) Individual refused to sign</p><p>( ) Communications barriers prohibited obtaining the acknowledgement</p><p>( ) An emergency situation prevented us from obtaining acknowledgement</p><p>( ) Other (Please Specify)</p><p>3 KENNETH M. LUBRITZ, D.D.S., INC.</p><p>Periodontics & Dental Implants</p><p>2500 Fondren, Suite 330</p><p>Houston, Texas 77063</p><p>CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION</p><p>SECTION A: PATIENT GIVING CONSENT</p><p>Name:______</p><p>Address:______</p><p>Telephone:______</p><p>Patient #______Social Security #______</p><p>SECTION B: TO THE PATIENT---PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY</p><p>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.</p><p>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.</p><p>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.</p><p>You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time contacting:</p><p>KENNETH M. LUBRITZ, D.D.S., INC.</p><p>4 KENNETH M. LUBRITZ, D.D.S., INC.</p><p>Periodontics & Dental Implants</p><p>2500 Fondren, Suite 330</p><p>Houston, Texas 77063 2500 Fondren Road, Suite 330</p><p>Houston, Texas 77063</p><p>Tel: (713) 789-7676</p><p>Fax: (713) 789-7051</p><p>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.</p><p>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.</p><p>Signature:______Date:______</p><p>If this Consent is signed by a personal representative on behalf of the patient, complete the following:</p><p>Personal Representative’s Name:______</p><p>Relationship to Patient:______</p><p>YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.</p><p>5</p>