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Kids off Broadway Dental, PLLCPatient Consent for Use and Disclosure of Protected Health InformationWith my consent, designated Kids off Broadway Dental personnel may use and disclose Protected Health Information (PHI) about me to carry out Treatment, Payment, and Healthcare Operations (TPO). This may include the use of phone calls, letters, emails, facsimiles, and text messages. Please refer to Kids off Broadway Notice of Privacy Practices for a more complete description of such uses and disclosures.I fully understand that I have the right to review the Notice of Privacy Practices prior to signing this consent. Kids off Broadway Dental reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the designated Kids off Broadway HIPAA Compliance/Security Officer at 721 Southpark Dr. Ste. A, Littleton, CO 80120.With my consent, Kids off Broadway personnel may mail to my home or other designated location any items that will assist Kids off Broadway Dental in carrying out TPO, such as appointment reminder cards and patient statements. When my information is disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient that is outside of Kids off Broadway Dental’s control. If I do not sign this consent, Kids off Broadway may decline to provide treatment to me, forward insurance claims on my behalf, or provide PHI to necessary sources outside the Kids off Broadway Dental practice.I have the right to revoke this authorization in writing except to the extent that Kids off Broadway has already made disclosures in reliance upon my prior consent. My written revocation must be forwarded to the Kids off Broadway HIPAA Compliance officer at 721 Southpark Dr. Ste. A, Littleton, CO 80120 to become legally effective and/or binding.By signing this form, I acknowledge receipt of notice of privacy practices, and consent to Kids off Broadway Dental’s use and disclosure of my PHI to carry out my TPO._________________________________________________________________________________________Patient’s NameLegal Guardian’s Name_________________________________________________________________________________________Signature of Patient or Legal GuardianDate ................
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