Patient Consent for Use and Disclosure of Protected Health Information

With my consent, designated Smiles of America personnel may use and disclose Protected Health Information (PHI) about me to carry out Treatment, Payment and Healthcare Operations (TPO). Please refer to Smiles of America 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. Smiles of America reserve the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the designated Smiles of America HIPAA Compliance/Security Officer, Smiles of America, 155 E Ray Road, Suite 4 Chandler, AZ 85225

With my consent. Smiles of America personnel may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assists Smiles of America personnel in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others.

With my consent, designated Smiles of America personnel may mail to my home or other designated location any items that will assist designated Smiles of America personnel in carrying out Treatment, Payment and Healthcare Operations (TPO), such as an appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

With my consent, designated Smiles of America personnel may e-mail to my home or other designated location any items that assist Smiles of America in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Smiles of America restrict how it uses or discloses my PHI to carry out TPO. However, Smiles of America is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Smiles of America use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that Smiles of America has already made disclosures in reliance upon my prior consent. If I do not sign this consent. Smiles of America may decline to provide treatment to me, forward insurance claims on my behalf, or provide protected PHI to sources Outside of the Smiles of America organization.