NOTICES OF PRIVACY PRACTICES ACKNOWLEDGEMENT CONSENT FORM

I understand that, under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.
I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses of disclosure of my health information. I understand that this organization has the right to change it Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Private Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Click here to view the Privacy Policies.
First Name:
Middle Initial:
Last Name:
Signature:
Date:
Relationship to Patient:

Photograph Release Consent Form

I hereby authorize Wall Orthodontics, LLC to take photographs of me or my minor child, identified herein, and to use such photographs and/or my name or the name of said minor child in their printed publications, on their web sites and in other social media.

I acknowledged that the inclusion of the name and photograph of myself or my minor child indentified herein in the printed publications, websites or social media of Wall Orthodontic, LLC does not confer upon either me or my minor child any rights or ownership interest whatsoever in said publications, web sites or social media.

I hereby release Wall Orthodontics, LLC, its contractors, employees, successors and assigns from any and all liability for any claims by me or any other third party on behalf of myself or my minor child in connection with the inclusion of the name or photograph of myself or my minor child in any printed publications, websites or social media of Wall Orthodontic, LLC.
Signature of Patient or Parent or Guardian of Patient if a Minor:
Date:
Street Address:
City, State, Zip:
Phone: