AMLEY & AMLEY D.D.S., P.A.

ACKNOWLEDGEMENT OF POSTED NOTICE OF PRIVACY PRACTICES
*You may refuse to sign this acknowledgement*

I, , have been offered a copy of the Privacy Practice Notice posted in the office of Amley & Amley D.D.S.

Please sign: Date:

AUTHORIZATION TO RELEASE HEALTH INFORMATION

I, , hereby authorize Amley & Amley D.D.S. located in Pinellas County, FL to display the photograph of the following patient inside the office on the photo board.

Patient/Parent signature:

(Revocation) I understand I may revoke this authorization at any time by sending a written notice to the practice.

(Refusal to Sign) I understand that I may refuse to sign this Authorization.
 
Refusal signature: Date:

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Purpose of this section is to inform you we need to use and disclose your protected health information to carry out treatment, payment activities, and healthcare operations. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: 727-381-1062 or frstavfl@orthodon.com. I understand that, by signing this Consent, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

Parent/Patient/Guardian Date: