HIPAA Notice of Privacy Practices

Starting April 14, 2003 the federal government has implemented the Health Insurance Portability and Accountability Act (HIPAA). It affects all doctors, hospitals, nursing homes, and anyone else that deals with Protected Health Information (PHI). Here at OHIOSmiles we have taken great steps in protecting your private health information. Attached you will find our HIPAA Notice of Privacy Practices. Federal law requires that you receive a copy and that you sign that you received a copy. The notice is yours to keep for your information. Please sign this page as it is proof that you have received your copy for our records.

Name: *

Phone: *

 

Email address: *

 

I have received a copy of the HIPAA Notice of Privacy Practices for OHIOSmiles. I have been given the opportunity to ask any questions regarding HIPAA and my Protected Health Information. *

Yes No  

I give consent to the following people to be able to talk about my PHI with Dr. Antalis and her staff.

Name:

 

Relationship:

 

Name:

 

Relationship:

 

I give consent to Dr. Antalis and her staff to leave messages at my home, work, or cell phone. *

Yes No  

Authorization/Consent

Consent by *

 

I the above named do hereby grant Denise Antalis, DDS and OHIOSmiles the authorization to photograph or video me. I understand that the images or video may be used in presentations, print publications, online publications, scientific journals, social media, websites, marketing, and other reasonable purposes for OHIOSmiles. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

Confirmation/Submission

By submitting this form I accept the above conditions and premissions as entered.

 

It may take a moment to submit your information. Please wait for a confirmation message.

 

OHIOSmiles

1500 Deerpath Drive
Cambridge, OH 43725

(740) 439-2501

Opening Hours

Monday & Tuesday: 8am–4pm
Wednesday: 11am–7pm
Thursday: 8am–4pm
Friday: 7am–3pm

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