Dental HIPAA Form

A HIPAA form provides authorization for particular disclosure of a patient's private health information.

Entities that must abide by HIPAA include health care providers, health plans, and health care clearinghouses.

Common HIPAA violations include a lack of proper data security, data breaches, insufficient employee training on HIPAA rules and regulations, improper disposal of confidential information, and unauthorized disclosure of patient information.

By scrolling to the top of the page and clicking on "Free Download," you'll be able to download our HIPAA form.

A dental HIPAA is important as it provides covered entities with authorization to use private health information for particular purposes.

Ensure Accurate & Complete Patient Info Provided

• Patient’s Full Name
• Patient’s DOB
• Other Source of Identification as Needed

Disclosure to Which Entity, Office or Party

• Another Dental Office
• Self
• Other (Indicate)

Method of Delivery

• Fax
• Postal Mail
• Email
• Pickup

What Information is Being Disclosed

Indicate the type of information

• Treatment Plans
• Radiology X-Rays & Images
• Billing Records
• Other Info

Option for Specific Instructions

• Allow option for Patient to Indicate What should not be Disclosed

Expiration Date of Disclosure

• Clear Indication of dates that Disclosure of information is permitted
• Ensure that the applicable dates are followed by your office
• If patient information is shared with a third party outside of the expiration date, you could face legal consequences

Signed Acknowledgement

• Patient or legal Guardian must sign the form
• Bypassing a patient’s signature can have legal ramifications
• Never Disclose patient’s information without their signed consent
• If patient is under the age of 18 be sure to have a legal guardian sign on their behalf