HIPAA Accompaniment

Patient Name

First

Last

Date of Birth

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

First

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