Client Consent Form

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process insurance reimbursement paperwork or requests for information.

The undersigned acknowledges opportunity to review and/or receive a copy of the currently effective Notice of Privacy Practices for this facility. A copy is available in the office, on our website and by email to the client upon request. A copy of this signed, dated document shall be as effective as the original.

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:

(This includes step parents, grandparents and any other care takers who can have access to this patients records):

I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT AND BILLING INFORMATION VIA:

I AUTHORIZE INFORMATION ABOUT MY SERVICES BE CONVEYED VIA:

I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES AND EVENTS BEING HELD BY RED BARN DENTAL:

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote or improve your health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

Electronic Signature of Patient (or Guardian). By typing your name in the space below you are providing an "electronic signature" and it indicates your approval of the information contained in this electronic form.