By signing this form you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.
You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice can accompany this consent upon request. We encourage you to read it carefully and completely if you have any questions before signing this consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
By signing this form you are giving Just for Kids Dental (Armin Aliefendic, DDS and Associates) consent and authorization to:
1) electronically file any insurance claims generated for reimbursement of dental procedures.
2) receive payment directly to Armin Aliefendic, DDS and Associates of the group insurance benefits otherwise payable to me.
3) release a school or work excuse for dental visits upon request.
4) automatically mail appointment reminder postcards and leave messages on my telephone answering machines.
5) post a picture of my child on the company's bulletin board within the office.
This consent is effective until such a date that the parent/guardian should decide to cancel this consent in writing. With the understanding that information obtained as a result of this consent may be used after the cancellation date. This information will be used only for the purpose it is intended.