HIPAA Accompaniment HIPAA Accompaniment Patient Name * Patient Name First First Last Last Date of Birth * Information to be used or disclosed. The information covered by this authorization includes: * All Records Health History Medications X-rays Dental Records Treatment Plan Billing OtherOther Persons to whom information may be disclosed and allowed to bring patient to dental appointments (Max 2) Name * Name First First Last Last Relationship * Address * Phone * Add Remove Expiration date of authorization The authorization is effective through: * Forever Certain Date Date 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 I, Your Name * , 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. Signature * Clear Relationship to Patient * Date If you are human, leave this field blank. Submit Δ