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Dental HIPAA Form Template

Ensure Patient Privacy with Our Dental HIPAA Form Template

Protecting patient privacy can feel overwhelming, but our Dental HIPAA Form Template makes it easy for you. Designed specifically for dental offices, this template helps you comply with HIPAA regulations while ensuring your patients' personal information is safeguarded. Streamline your patient intake, maintain confidentiality, and build trust with your clients, all while easily customizing the document to suit your needs. Experience the benefits of automated compliance and sit back knowing you're covered-check out the live template at your convenience.

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Primary phone number
Email address
Representative full name (if not the patient)
Relationship to patient (if applicable)
Your role
I am the patient
Parent or legal guardian
Personal representative or power of attorney
Other
Please Specify:
Comments or request for a copy (optional)
I acknowledge that I received or had the opportunity to review the Notice of Privacy Practices
Yes
No
I authorize the practice to use and disclose my protected health information (PHI) for treatment, payment, and healthcare operations
Yes
No
Individuals authorized to receive my PHI (list names and relationship)
Describe any requested restrictions (if applicable)
Security code word for identity verification (optional)
Do you wish to place any specific restrictions on the use or disclosure of your PHI?
Yes
No
Preferred method of contact
Phone call
Text message
Email
No preference
I consent to the following methods for appointment reminders and care-related messages
Voicemail at the phone number provided
Text message at the phone number provided
Email to the email address provided
Do not send any reminders or messages
May we leave detailed messages about treatment or billing on voicemail?
Yes
No
May we send you educational or promotional materials (e.g., newsletters, special offers)?
Yes
No
May we use de-identified images or information for education or marketing?
Yes
No
I understand I may revoke this authorization in writing at any time, as permitted by law
Yes
No
Typed signature of patient or authorized representative
Date signed
I certify that the information provided is accurate and that I am authorized to complete this form
Yes
No
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Paper art illustration for Dental HIPAA Form Template article showcasing design and layout elements

When to use this form

Use this patient privacy and consent form at check-in for new patients, before a procedure, or when you update office policies. It captures who you may speak with about the patient's care, how to contact them, and acknowledgment of your privacy practices. In a busy practice, this prevents delays, reduces call-backs, and protects your team when sharing records or billing insurers. For a complete intake packet, pair it with the Dental health assessment form and the Dental history form. It is also helpful during annual updates, after a name or contact change, or when a parent or caregiver needs to be added or removed from the file.

Must Ask Dental HIPAA Questions

  1. Who can we discuss your care with and what information may we share?

    This defines approved contacts (family, caregiver, or translator) and the limits staff must follow. Clear permissions prevent unauthorized disclosures and speed coordination during referrals.

  2. How may we contact you about appointments, billing, and test results?

    Preferred channels (call, text, email) and times reduce missed messages and support secure communication. It also tells staff what not to do, such as leaving PHI on a shared voicemail.

  3. Do you authorize us to request and share your records with other providers for treatment?

    This enables compliant information exchange for continuity of care. It keeps details aligned with your Dental treatment plan form when coordinating specialist visits.

  4. Do you consent to use and disclose your information for payment and insurance purposes?

    With consent, staff can verify eligibility, submit claims, and appeal denials. This pairs well with the Dental insurance breakdown form to avoid coverage surprises.

  5. Have you received and acknowledged our Notice of Privacy Practices?

    This documents that the patient understands rights, how their information is used, and how to request restrictions or access. It also provides proof of compliance during audits.

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