Patient's Consent to the Use and Disclosure 
of Health Information for Treatment, Payment, or Healthcare Operations

	I, _____________________________________________________, understand that as part of my health care, 1.  Joseph D. Chipriano,Jr., D.M.D. originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment.  I understand that this information serves as:  

* A basis for planning my care and treatment,
* A means of communication among the many health professionals who conribute to my care,
* A source of information for applying my diagnosis and surgical information to my bill,
* A means by which a third-party payer can verify that services billed were actually provided, and  
* A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare     professionals.

*I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and  disclosures.  I understand that I have the following rights and privileges:

*  The right to review the notice prior to signing this consent,
*  The right to object to the use of my health information for directory purposes, and
*  The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations.

I understand that 1.  Joseph D. Chipriano,Jr., D.M.D. is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.  I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.  I further understand that 1. Joseph D. Chipriano, Jr., D. M.D. reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations.  Should 1.  Joseph D. Chipriano, D.M.D. change their notice, they will send a copy of any revised notice to the address I've provided (whether U.S. mail or, if I agree, email).
I wish  to have the following restrictions to the use or disclosure of my health information:
____________________________________________________________________________________________________________________________________________________________________

I understand that as part of this organization's treatment, payment, or health care operations, it may become necessary to disclose my protected health informaton to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax.

I fully understand and accept/ decline the terms of this consent.
I understand and agree to treatment in an open treatment area environment.

_________________________________________________________Date:________________
Patient's Name

_________________________________________________________Date:________________
Parent or Guardian's Signature