2026 HIPAA Form

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

• Provide and coordinate my treatment among a number of healthcare providers who may be involved in the treatment directly and indirectly.
• Obtain payment from third-party payers for my healthcare services.
• Conduct normal healthcare operations such as quality assessment and improvement activities.

I have been informed of my dental provider’s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office to obtain a current copy of the Notice of Privacy Practices.

Substance Use Disorder (SUD) Records
I understand that certain records related to substance use disorder (SUD) treatment may be protected by federal law (42 C.F.R. Part 2) and may be subject to additional privacy protections beyond HIPAA. If such records exist, they may not be used or disclosed except as permitted by law or with my written consent.

I understand that I may request in writing that this office restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations and I understand that this office is not required to agree to my requested restrictions, but if it is agreed upon, then this office is bound to abide by such restrictions.