Jeffrey C.H. Chow, DDS 

Diplomate, American Board of Periodontology 

Periodontics-Implantology 

HIPAA Compliance Patient Consent Form 

 Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. 

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you  have reviewed our notice before signing this consent. 

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. 

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare  operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health  Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or  healthcare operations. 

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous  usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not  be retroactive. 

By signing this form, I understand that: 

·Protected health information may be disclosed or used for treatment, payment, or healthcare operations. 

·The practice reserves the right to change the privacy policy as allowed by law.

·The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions. 

·The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. 

·The practice may condition receipt of treatment upon execution of this consent. 

May we phone, email, or send a text to you to confirm appointments? YES NO 

May we leave a message on your answering machine at home or on your cell phone? YES NO

May we discuss your medical condition with any member of your family? YES NO

If YES, please name the members allowed: 

___________________________________________________________________________________

___________________________________________________________________________________

This consent was signed by: _________________________________________________________ 

(PRINT NAME PLEASE) 

Signature:_____________________________________________________Date:________________

Witness:______________________________________________________Date:________________