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HIPAA PRIVACY AUTHORIZATION FORM
Authorization for Use or Disclosure of Protected Health Information(Required by the Health Insurance Portability and Accountability Act-45 CPR Parts 160 and 164)
1)Authorization form release of PHI Covering the periodof health care (check box)
All past, present and future periods.
2) In addition to the authorization for release of my PHI, I authorize disclosure of information regarding my billing, condition, treatment, and prognosis to the following individual(s):
This authorization shall be in force and effect until nine(9) months after my death or Authorization Pulled , (date or event) at which time this authorization expires. I understand that I have the right to revoke this authorization, in writing, at any time. Iunderstand that a revocation is not effective to the extent that any person or entity has already acted in reliance on the authorization or if the authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
Signature of Patient
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1268 West Ohio Pike
Amelia, OH 45102
*Select Saturday Hours Available 8AM – 1PM
At Buckeye Dental we accept All PPO’s. Additionally, we accept cash, check, Visa, Mastercard, Discover and debit cards.
Dear Valued Patient,
We have great news! Buckeye Dental is opening back up for regular and elective dental work. We will always see emergency patients, too.
You are the most important members of our dental family, and we want you to be safe. Therefore, we made some changes to how visits are structured. We look to meet or exceed the guidelines set by the American Dental Association or the U.S. Center for Disease Control. Our hours have changed are posted on our website. Please regularly check it for any updates or changes.
When you call for an appointment we will check if you have any fever or cough. Upon arrival you can wait in the convenience of your car and as soon as the health care provider is ready to go we will text you. Then we greet you at the door to avoid any unnecessary risk to you.
Our goal is to keep everyone protected. While we love seeing your smiles, patients must wear a face mask in the office before and after the exam. We will also have hand sanitizer available at the entrance. Our staff will all be properly equipped with masks and gloves. The exam rooms will be thoroughly cleaned before and after each appointment.
Thank you for being a loyal Buckeye Dental patient during these trying times!