TESTIMONIALS

CALL FOR AN APPOINTMENT
410.551.4600

Smiling People
HELPFUL FORMS & RESOURCES CURRENT OFFERS GLOSSARY

CONTACT US FOR MORE INFO

 

RECENT POSTS

Recent Posts

Consent for Use and Disclosure of Health Information


Legal and Privacy > Consent for Use and Disclosure of Health Information


Section A: Patient Giving Consent

 

Name

 

 

Address

 

 

Tel

 

 

e-Mail

 

 

Patient Number

 

 

Social Security Number

 

return to top


Section B: To the Patient—Please read the following statements carefully.

Purpose of Consent: 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.

Notice of Privacy Practices: 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 accompanies this Consent. We encourage you to read it carefully and completely 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, wewill 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.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

return to top


Contact Officer: Mark J. Gasbara D.D.S.

Telephone: 410.551.4600 Fax: 410.674.5551

E-mail: Mark@MarkGasbaraDDS.com

Address: 1215 Annapolis Road, Suite 208, Odenton, MD 21113

return to top


Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

return to top


Signature
I, ______________________________________________, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and heath care operations.

 

Signature

 

 

Date

 

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

 

Personal Representative’s Name

 

 

Relationship to Patient

 

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.

 

Include completed Consent in the patient’s chart.

return to top


Revocation of Consent

I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations. I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent.

 

Signature

 

 

Date

 

return to top


© 2002 American Dental Association All Rights Reserved

Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.

This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).

return to top

Dr. Mark Gasbara
  • Office Hours


    • Monday: 10:00 AM − 5:00 PM
    • Tuesday: 12:00 PM − 8:00 PM
    • Wednesday: 10:00 AM − 4:00 PM
    • Thursday: 12:00 PM − 5:00 PM
    • Friday: Closed
    Add a Review
  • Office Location


    Dr. Mark J. Gasbara D.D.S.

    1215 Annapolis Road, Suite 208, Odenton, MD 21113
    Phone: (410) 551-4600
    Fax: 410-674-5551

    E-mail Us
    Location & Directions