College Avenue Dental – HIPAA Consent and Agreement

Effective August 6, 2013

I consent to the use or disclosure of my “protected health information” as defined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and this Consent by College Avenue Dental for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct the health care operations of College Avenue Dental.I understand that diagnosis or treatment of me by Dr. Randall E. Lawson may be conditioned upon my consent as evidence by my signature on this document or electronically for this document.

My “protected health information”(PHI) means health information, including but not limited to my demographic information, collected from me and created or received by College Avenue Dental, another health care provider, a health plan, my employer, or a health care clearinghouse. This protected health information relates to my past, present, or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe such information may identify me.

I understand that I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment, or the healthcare operations of College Avenue Dental. College Avenue Dental is not required to agree to any restriction that I may request. If, however, College Avenue Dental agrees to any restriction requested by me, such restriction shall be binding on College Avenue Dental and Dr. Randall E. Lawson.I further understand that I have the right to revoke this consent, in writing, at any time, except to the extent that Dr. Randall E. Lawson or College Avenue Dental has taken action in reliance on this consent.

I understand I have a right to review College Avenue Dental’s Notice of Privacy Practices prior to signing this consent. College Avenue Dental’s Notice of Privacy Practices has been provided to me and describes the types of uses and disclosures of my protected health information that may occur in my treatment, payment of my bills, or in the performance of health care operations of College Avenue Dental. This includes calling the pharmacy of your choice regarding your prescriptions. This Notice of Privacy Practices also describes my rights and College Avenue Dental’s duties with respect to my protected health information.

Please also note that as provided in College Avenue Dental’s Notice of Privacy Practices, College Avenue Dental reserves the right to change the privacy practices that are described in such notice. I may obtain a revised notice of privacy practices by accessing the College Avenue Dental website, calling the office at (217) 245-5319, and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.

I also consent to the College Avenue Dental Internet Communications Consent form. I have been provided and read the information regarding the secured uploading of patient information to the website for the dental practice and grant College Avenue Dental permission to securely upload my patient information to the website.

It is important that College Avenue Dental contact you regarding upcoming appointments or regarding a need to change an appointment with our office. I give my permission for Dr. Randall Lawson and staff to leave a message by telephone with a family member or on a home telephone recorder; send notices by mail; leave a message by email and/or text message, or leave a message at my place of employment requesting me to call the office. If I do not wish to be contacted at any of the above places, I will sign a declination form that I can get from the receptionist at College Avenue Dental.

I understand that College Avenue Dental has a sign-in sheet at the registration desk that asks me my name and/or Initials and about Text Messaging, Email, and my method of payment. I give College Avenue Dental permission to have this information at the registration desk and understand that other people may see the information. I understand that I have the right not to give any of this information on the sign-in sheet at the registration desk.

I give permission for employees of College Avenue Dental to call me by first and last name in the waiting room when Dr. Randall E. Lawson or the hygienist is ready to see me.

College Avenue Dental is obligated to notify you in the event of a breach of unsecured protected health information.

College Avenue Dental will obtain a written authorization from you if there is a disclosure of your PHI for marketing purposes or the sale of your PHI.

In the event you pay in full for a service out of pocket, you now have the right to request that College Avenue Dental not disclose treatment information for this service to a health plan.

You have the right to inspect and copy your protected health information, which includes the right to an Electronic copy of your records if you prefer.

Internet Communications Consent

I grant my permission to College Avenue Dental to upload and store confidential patient information (including account information, appointment information, and clinical information) to the secured website for the dental practice. I understand that for security purposes, the site requires a user ID and password for access and use. I also understand that College Avenue Dental and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice website with my ID and password. I also agree to immediately notify College Avenue Dental of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.

I also understand that State and Federal Laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limits the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of the agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload, and use my information in connection with the operation of such services and is acting on my behalf in uploading my patient information. I understand that College Avenue Dental will use commercially reasonable efforts to maintain the confidentiality of all patient information uploaded to the website on my behalf.

I understand that College Avenue Dental CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED, OR RECEIVED USING THE SITE OR THE SERVICES.