Calian Dental Group
445 Hamilton Avenue, Ste. 220
White Plains, NY, 10601
914-949-3371

PATIENT CONSENT FORM

I understand that I have certain rights to privacy regarding my protected health information. These are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:
  • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
  • Obtaining payment from third party payers(e.g. my insurance company);
  • The day-to day healthcare operations of your practice.
I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice form time to time and that I may contract you at time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However; any use or disclosure that occurred prior to the date I revoke this consent is not affected.

Patient Name

Relationship To Patient

NOTE: You will have an opportunity to DATE and SIGN this form during you next visit.
Signed this ______ day of ________________, 20 ____.
Signature: ____________________________________________