Download Dr. Karessa A. Kuntz, DDS - Smile Beautiful Dentistry

Dr. Karessa A. Kuntz, DDS
Practicing General Dentistry
100 James Place, Monroeville PA
(t) 412 372 7192 (f) 412 457 1016
Consent for Use and Disclosure of Health Information
Name
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Address
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Telephone
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Social Security #
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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.
Notice of Privacy Practices: Our notice is as follows: We safely and securely keep your health history, dental history, medications, allergies and
insurance information on file in our office. By providing us with this information, you allow us to treat you safely while in our office. We securely
keep record of what is performed in our office and share it only with your insurance company to receive payment for the procedures performed.
At times, we may need to share your dental or health history with other professionals that are treating you – such as your Pharmacist or another
dental professional that we are referring you to. We will never sell or disclose your dental or health information, name, address, telephone number
or social security number to any entity. The majority of insurance companies use your social security number as your ID number, and is the sole
reason we need your social security number.
We reserve the right to change our privacy practices.
By signing below, you recognize the purpose of us keeping your protected health information. If you refuse to allow us to keep your information on
file, we may need to decline treating you.
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Patient Signature
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