I, _____________________________________, hereby authorize Abide Free Clinics and Poulsbo Seventh-day Adventist Church to use, reproduce and/or publish all written and/or visual materials, including photographs that may pertain to me. I understand that this material may be used in various publications, press releases, or for other related endeavors. This material may also appear on the website of Poulsbo Seventh-day Adventist Church. This authorization is continuous and may only be withdrawn by my specific recession of this authorization. Consequently, Poulsbo Seventh-day Adventist Church may publish materials, use my name, photograph, and/or make reference to me in any manner that Poulsbo Seventh-day Adventist Church deems appropriate for publicity opportunities.
This ABIDE health clinic is for low-income patients who have a dental or vision problem and no dental/vision insurance (private or Medicaid coverage) or the financial means to pay for care at this time. Licensed volunteer dentists/vision practioners utilizing ABIDE Free Health Clinics will provide treatment. I understand that the dentist(s)/vision practitioner(s) providing the services is/are doing so without receiving payment directly from me, the patient. I understand and acknowledge that the dentist(s)/vision practitioner(s) providing treatment is/are under the supervision of ABIDE Free Health Clinics is/are not controlled by the organizations providing support to the free health clinic. I hereby authorize and direct the dentist(s) and vision practitioners of Abide Free Health Clinics and/or dental/vision auxiliaries of their choice, to perform the following dental treatment, oral surgery, and/or vision procedure(s), including the use of any necessary or advisable local anesthesia, radiographs (x-rays), or diagnostic aids.
there are risks involved in this treatment and hereby acknowledge that these risks will be explained to me, that I will have the opportunity to ask questions regarding the treatment and the risks, and that I fully understand the same. I will be advised that the success of the dental/vision treatment to be provided will require that the patient and/or guardian(s) of the patient follow post-operative and post-care instructions of the dentist(s)/vision practitioner(s). I agree that the success of the treatment requires that all post-operative and post-care instructions be followed and that regular office visits as scheduled by my dentist/vision practitioner and their auxiliaries must be maintained.
during the course of treatment unforeseen circumstances may necessitate additional or different procedures from those discussed. I therefore authorize and request the performance of any additional procedures that are deemed necessary or desirable to oral/vision health and well-being, in the professional judgment of the dentist/vision practitioner. There are possible risks and complications associated with the administration of local anesthesia, sedation, and drugs. The most common of these are swelling, bleeding, pain, nausea, vomiting, bruising, tingling, and numbness of the lips, gums, face, and tongue, allergic reactions, hematoma (swelling or bleeding at or near the injection site), fainting, risks such as unfavorable reactions to medications in respiratory and cardiovascular collapse (stopping of breathing and heart function) and lack of oxygen to the brain that could result in coma or death. I understand and have been informed of the above risks and complications.
the use of local anesthesia depending on the judgment of the dentist. I understand and have been informed of the above risks and complications.
the dentists/vision practitioners to use photographs, radiographs, other diagnostic materials, and treatment records for the purpose of teaching, research, and scientific publications.
I have read and understand this consent, and that all questions about the procedures will be answered in a satisfactory manner, and I understand that I have the right to be provided answers to questions which may arise during and after the course of my treatment. I further understand that this consent will remain in effect until such time that I choose to terminate it.
This notice describes how health information about you may be used. Please review it carefully. We are required by law to maintain the privacy of protected health information (PHI), to provide privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect on the date of signing and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all health information that we maintain. When we make significant changes in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
We may use and disclose your health information for different purposes, including treatment and health care operations. For each of these categories, we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records.
We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities. We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make healthcare decisions for you, we will treat that patient representative the same as we would treat you with respect to your health information.
We may use or disclose your health information to assist in disaster relief efforts.We may use or disclose your health information when we are required to do so by law. We may disclose to military authorities the health information of Armed Forces personnel under circumstances. We may disclose authorized federal officials the health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody, the PHI of an inmate or patient.
We may disclose your health information for public health activities, including disclosures to: Prevent or control disease, injury, or disability, Report child abuse or neglect, Report reactions to medications or problems with products or devices, Notify a person of a recall, repair, or replacement of products or devices, Notify a person who may have been exposed to a disease or condition, Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.
We will disclose your health information to the Security of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA. We will disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law. We may disclose your PHI or law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order. If you are involved in a lawsuit or dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.
We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws. We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information. We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine cause of death. We will also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties. We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications.
Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this notice (or as otherwise permitted or required by law). you may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.
You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible. We will charge a reasonable cost-based fee for the cost of supplies and labor of copying, and for the postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an explanation of our fee structure. If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.
With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you request this accounting more than once in a 12-month period, we may charge you a reasonable cost-based fee for responding to the additional requests.
You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure, or both, and (3) to whom you want the limits to apply. We are not required to agree with your request except in the case where disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full.
You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. You must make your request in writing. Your request must specify the alternative means or location and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested, we may contact you using the information we have.
You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.
You will receive notifications of breaches of your unsecured protected health information, as required by law. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S.Department of Health and Human Services.
