HIPAA Accompaniment

HIPAA Accompaniment
Patient Name
Patient Name
First
Last
Information to be used or disclosed. The information covered by this authorization includes:

Persons to whom information may be disclosed and allowed to bring patient to dental appointments

(Max 2)
Name
Name
First
Last

Expiration date of authorization

The authorization is effective through:
unless revoked or terminated earlier by the custodial parent and/or guardian

Right to Terminate or Revoke Authorization

You may revoke or terminate this authorization by submitting a written revocation to the practice. You should contact the Privacy Officer to terminate this authorization

Potential for Re-Disclosure

Information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by federal or state law.

Signature

, have had full opportunity to read and consider the contents of the consent form and your Notice of Privacy Practices. I understand that, by signing this consent form, I authorized persons named above are not Medicaid service providers or employed by or affiliated with Northeast Children’s Dentistry, Inc.

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