Edward P. Allen, DDS, PhD

Consent for Disclosure of Health Concerns

My personal health information is private and confidential. I understand that my doctor and his staff work very hard to protect and preserve the confidentiality of my personal health information.

I understand that my doctor and his staff may use and disclose my personal health information to help provide health care to me, to handle billing and payment, and to take care of other health care operations. There will be no other uses and disclosures of this information unless I permit it. However, I understand that sometimes the law may require the release of this information without my permission.

I can ask my doctor to limit how my health information is used or disclosed to carry out treatment, payment or health care operations. I understand that my doctor does not have to agree to my request, I understand that my doctor and his staff would follow the agreed limits.

I may cancel this consent at any time by doing one of the following:

1) Signing and dating a form that my doctor or his staff give me called “Revocation of Consent for Use and Disclosure of Health Information”; or

2) Writing, signing and dating a letter to my doctor directly. If I write this letter, it must say that I want to cancel my consent to authorize the use and disclosure of my personal health information for treatment, payment and healthcare operations.

If I cancel this consent, my doctor and his staff do not have to provide any further health care services to me.

My doctor has a detailed document called the “Notice of Privacy Practices”. It contains more information about the policies and practices protecting my privacy. I understand that I have the right to read the “Notice” before signing this agreement. My doctor may update this “Notice”. If I ask, my doctor and his staff will provide me with the most current “Notice”.

My signature below indicates that I have been given the chance to review a current copy of my doctor’s “Notice of Privacy Practices”. My signature means that I agree to allow my doctor to use and disclose my personal health information to carry out treatment, payment and healthcare operations.

Patient/ Legal Guardian Signature