Crawford & Colvin DDS
Patient Consent Form

The Health Insurance Portability and Protection Act (HIPPA) require that all medical providers, insurance companies and others put in place controls to ensure that your personal dental information is safe. Crawford & Colvin DDS PA requests that each patient sign this consent form which allows us to share protected health information with other physician offices, hospitals and insurance company. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. 

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this consent. 

Signature of Patient or Representative: _____________________ Date __________________ 

Authorization to Release Information to Family Members

Many of our patients allow family members such as their spouse, parents or others to call and request the results of tests, procedures and account information. Under the requirements for HIPPA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have information released to family members you must sign this form. Signing this form will only give consent to release this information to the family members indicated below. This consent form will not allow employees of Crawford & Colvin DDS PA to release any other information to these family members. 

You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. 

I authorize Crawford & Colvin DDS PA to release information noted above to the following individuals. 

_______________________ Relation to Patient: __________________ Date:______________ 

_______________________ Relation to Patient: __________________ Date: ______________

Signature of Patient / Representative: ______________________________________________ 

Authorization to Leave Messages with Household Members/Answering Machine

From time to time it is necessary for representatives of Crawford & Colvin DDS PA to leave messages for patients. The purposes of these messages is to remind patients that they have an appointment, to notify the patient that the dental staff would like to discuss lab results, treatment procedures and account information. At no time will a representative of Crawford & Colvin DDS PA discuss your dental circumstances or condition without your consent. The purpose of this consent is to leave messages with members of your household or on your answering machine. 

You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. 

Patient Signature:	___________________________ 	Date:	__________________________