Health Information Consent Form Evergreen Dental uses health information within their office to provide the best dental care possible. Evergreen Dental has my consent to use or disclose my protected health information* to carry out treatment, obtain payment from insurance companies, and for health care operations like quality reviews. In addition, they may share health information with physicians, referring dentists, clinical laboratories, pharmacies or other health care personnel providing treatment. Health information may be included with an invoice used to collect payment for treatment received. The same applies to insurance forms filed via mail or sent electronically. Because Evergreen Dental believes regular care is very important to oral and general health, reminders will be given of scheduled appointments or appointments to be scheduled. These communications are an important part of Evergreen Dental’s philosophy of partnering with patients to be sure they receive the best dental care. This may include postcards, letters, telephone reminders, texts, or electronic reminders such as e-mail (unless otherwise indicated). I have been informed that I may review Evergreen Dental’s Notice of Privacy Practices (for a more complete description of uses and disclosures) before signing this consent. I understand that Evergreen Dental has the right to change their privacy practices and that I may obtain any revised notices at Evergreen Dental. I understand I have the right to request a restriction of how my protected health information is used. However, I also understand that Evergreen Dental is not required to agree with this request. If Evergreen Dental agrees to my requested restriction, they must follow the restriction(s). I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed.Name Relationship to Patient (if other than self)Signature*Date Month Day Year *Protected health information to include radiographs, intra-oral and extra-oral pictures, and chart notations.