The information that I have given is correct, to the best of my knowledge. I understand that it is my responsibility to inform this office of any changes in my / my child's medical or dental status.
I request that the doctors and staff of SmileLife Orthodontics transfer manually and/or electronically all information related to payment for and treatment of my / my child's orthodontic case to other dentists, physicians, insurance companies, Medicaid programs, and support communities (i.e., custom appliance labs, computerized study model companies). Such reports may include, but are not limited to, medical, dental, and orthodontic care and treatment; illness or injury; dental and medical history; consultation; prescriptions; X-rays; photographs; models; and all copies of financial payment, dental, and medical records.
I also authorize the dental staff to perform the necessary dental services that I / my child may need during treatment.
This notice describes how your medical information may be used and disclosed, and how you can receive this information. Please review it carefully.
When it comes to your health information, you have certain rights. This section explains your rights and our responsibilities to help you.
Get an electronic or paper copy of your medical record.
Ask us to correct your medical record.
Request confidential information.
Ask us to limit what we use or share.
Get a list of those with whom we’ve shared information.
Get a copy of this privacy notice.
Choose someone to act for you.
File a complaint if you feel your rights are violated.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases, we never share your information unless you give us written permission:
In the case of fundraising:
How do we typically use or share your health information? We typically use or share your health information in the following ways:
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization.
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services.
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more info see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues.
We can share health information about you for certain situations such as preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic violence, and/or preventing or reducing a serious threat to anyone’s health or safety.
We can use or share your information for health research.
Comply with the law.
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests.
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director.
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests.
We can use or share health information about you:
Respond to lawsuits and legal actions.
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
I acknowledge receiving the practice's "Notice of Privacy Practices" dates 3/5/2021.
I hereby voluntarily authorize the disclosure of information from my health record. I understand that I may revoke this authorization at any time in writing and submitted to the Covered Entity above, except to the extent that action has been taken in reliance on this authorization.
The information from my health record is to be disclosed by the Covered Entity above and provided to the following:
In consideration of my engagement as a model, upon the terms herewith stated, I hereby give to SmileLife Orthodontics*, legal representatives and assigns, those for whom SmileLife Orthodontics is acting, and those acting with his/her authority and permission:
A) The unrestricted right and permission to copyright and use, re-use, publish, and republish photographic portraits or pictures of me or in which I may be included intact or in part, composite or distorted in character or form, without restriction as to changes or transformations in conjunction with my own or a fictitious name, or reproduction hereof in color or otherwise, made through any and all media now or hereafter known for illustration, art, promotion, advertising, trade, or any other purpose whatsoever.
B) I also permit the use of any printed material in connection therewith.
C) I hereby relinquish any right that I may have to examine or approve the completed product or products or the advertising copy or printed matter that may be used in conjunction there-with or the use to which it may be applied.
D) I hereby release, discharge and agree to save harmless SmileLife Orthodontics, legal representatives or assigns, and all persons functioning under his/her permission or authority, or those for whom he/she is functioning, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form whether intentional or otherwise, that may occur or be produced in the taking of said picture or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy.
E) I hereby affirm that I am over the age of majority and have the right to contract in my own name or contract for the minor listed below who will appear in the photo shoot. I have read the above authorization, release and agreement, prior to its execution; I fully understand the contents thereof. This agreement shall be binding upon me and my heirs, legal representatives and assigns.