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13535 Hausman Pass, Suite 102

13535 Hausman Pass, Suite 102 2025

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The document is a Patient Consent Form from Kimberly Voges, D.D.S., outlining the use and disclosure of protected health information in accordance with HIPAA regulations. It informs patients of their rights regarding privacy practices, the ability to request restrictions on information use, and the process for revoking consent. By signing, patients consent to the use of their information for treatment, payment, and healthcare operations.

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Click ‘Get Form’ to open the Patient Consent Form in the editor.
Begin by reviewing the Notice of Privacy Practices provided in the document. This section outlines your rights regarding your protected health information.
In the designated area, print your name as the patient or representative. Ensure that this is clear and legible.
Next, sign the form where indicated. This signature confirms your consent for the use and disclosure of your health information.
If applicable, have a practice representative sign and print their name in the specified fields to validate the consent.
Finally, enter the date of signing in the provided space to complete the form.

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2020	4.5 Satisfied (56 Votes)
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