• Section A: Patient Giving Consent

  • Date Format: MM slash DD slash YYYY

  • 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.

    Assignment of Benefits: I hereby authorize and direct payment of insurance benefits otherwise payable to me, directly to Todd M. Bennett DDS, MDS, PC. I understand that I am financially responsible for any charges not covered. I understand that by signing this form I am accepting financial responsibility for services rendered.

    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, 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

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

    Contact Person: Office Manager
    Telephone: 251.471.8008
    Fax: 251.471.0018
    Email: [email protected]
    Address: 3210 Old Shell Road Mobile, AL 36607

    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.

  • Signature

  • Date Format: MM slash DD slash YYYY
  • If this Consent is signed by a personal representative on behalf of the patient, complete the following: