FREE Exclusive Access to Our HIPAA Form 2026
Download our updated HIPAA form template as a starting point for your practice’s privacy documentation. Review it with your own compliance advisor before use.
HIPAA of 1996 mandates data privacy and security for safeguarding patient's medical information.
Learn More About HIPAA Compliance Regulations
HIPAA requires healthcare facilities to safeguard and maintain confidentiality of all electronic protected health information.
Maintain the confidentiality, integrity, and availability of electronic protected health information that is created, received, maintained or transmitted.
Identify and protect against reasonably anticipated threats to the patients information & security.
Provide appropriate workforce training and enforce your policies and procedures.
mConsent Online Dental Intake Forms, Backed by a HIPAA Business Associate Agreement
Learn how mConsent supports your practice’s HIPAA privacy and security workflows
Schedule a Demo
General HIPAA Privacy Breaches in Dental Offices
Not properly maintaining confidentiality of patient data via encryption.
Failing to attain patient authorization prior to release of personal information.
Improper discarding of patient data via paper forms.
Streamline Your Practice with Digital Patient Intake Forms
Patients Can Complete Forms Remotely
Integrates with Major EMR Software
Personalize Your Own Patient Forms
Scan ID, Insurance Card & More
Patient Data Stored in the Cloud System
Customized iPad for In-Office Use
Eliminate Tedious Paperwork & Reduce 35% of Documentation Time
Schedule a DemoSwitch to cutting edge technology by going paperless with mConsent
FAQs on HIPAA Forms
A HIPAA form is a document that protects your medical information. It enables healthcare providers to share your health information only with those you permit.
Entities that must abide by HIPAA include health care providers, health plans, and health care clearinghouses.
HIPAA standards prohibit sharing medical information without permission, accessing data without authorization, discussing patients in public, and leaving sensitive documents where others can see them.
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 form documents how your health information may be used and disclosed by the practice, and records your acknowledgment of its privacy notice. HIPAA also permits certain uses and disclosures without your separate authorization, such as for treatment, payment, and healthcare operations.
A dental HIPAA form typically includes personal information like name, address, and insurance details. It also covers consent for treatment and acknowledges an understanding of privacy policies. Additionally, it may include medical history, medications, and emergency contacts. All this ensures patient confidentiality and compliance with HIPAA regulations.
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
- Pickup
What Information is Being Disclosed
- 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
Success Stories
Individual results are not typical and will vary. The experiences below are the individual customers' own reported outcomes and are not a guarantee or projection of similar results for your practice.
Grace
“Before mConsent everything was definitely more labor intensive, lots of time consuming paperwork that we don't have to do now with mConsent.”
Individual result — not a guarantee of similar outcomes.
Adira “Dee” Bailey
“Before using mConsent I had to print out the router sheet everyday and get the patient's signature, very time consuming.”
Individual result — not a guarantee of similar outcomes.
Stefanie Daley
“Before using mConsent we had to find and pull patients' charts and input data, it takes a lot of time.”
Individual result — not a guarantee of similar outcomes.
Important disclosures
This form is a general template provided for informational purposes only. It is not legal advice, and downloading or using it does not by itself make your practice HIPAA compliant. HIPAA compliance requires a risk analysis, written policies and procedures, workforce training, Business Associate Agreements, and administrative, physical and technical safeguards. Have your own counsel or compliance advisor review any form before you use it with patients. Testimonials describe individual results that are not typical. mConsent operates as a Business Associate under HIPAA and executes a BAA with each customer.
Not legal or compliance advice. This page and the downloadable form are general information for dental practices. They are not legal advice, do not create an attorney-client or consultant relationship, and are not a substitute for guidance from your own qualified counsel or compliance professional. mConsent is a software vendor, not a law firm and not a compliance certification body. Laws, regulations, and enforcement guidance change, and requirements differ by state and by practice. Consult your own advisors before adopting any form, policy, or procedure.
The form is a template, not compliance. Downloading, printing, or using this form does not make a practice HIPAA compliant and does not establish that a practice meets any federal or state requirement. HIPAA compliance is an ongoing program that includes a documented security risk analysis, written policies and procedures, designated privacy and security officials, workforce training and sanctions, incident response and breach notification processes, Business Associate Agreements with vendors, and administrative, physical, and technical safeguards. A single acknowledgment form addresses only a narrow part of that. No vendor, product, or document can make a practice compliant on its own.
Review and adapt before use. This template is generic and has not been drafted for your practice, your state, your specialty, or your specific workflows. It may not reflect the most recent regulatory guidance at the time you download it. Review and adapt it with your own counsel before putting it in front of patients, and confirm it works alongside your Notice of Privacy Practices and your existing consent and authorization documents. Your practice is solely responsible for the forms it uses.
Statements about HIPAA on this page. Summaries of HIPAA requirements, common privacy breaches, and what a dental HIPAA form typically contains are simplified general descriptions for orientation. They are not a complete or authoritative statement of the Privacy Rule, Security Rule, or Breach Notification Rule, and should not be relied on to determine your obligations. Refer to the regulations themselves and to guidance from the U.S. Department of Health and Human Services, or ask your advisors.
mConsent's role under HIPAA. mConsent operates as a Business Associate under HIPAA and executes a Business Associate Agreement (BAA) with each customer, maintaining administrative, physical, and technical safeguards. Your practice remains the Covered Entity and retains responsibility for its own compliance program, for lawful use of the platform, and for obtaining any patient consents and authorizations required by law. A BAA governs mConsent's handling of protected health information; it is not a certification of your practice's compliance. View our security practices
Testimonials & individual results. Customer testimonials reflect individual experiences and are not typical results. Time savings and workflow improvements described are the customer's own reported experience for their specific practice, have not been independently audited by mConsent, and are not a guarantee or projection of similar outcomes for your practice.
Download form & contact consent. Submitting the download form provides your information to mConsent so we can deliver the requested material and contact you about mConsent. You may opt out of marketing contact at any time using the unsubscribe link in our emails. Patient text communications sent through the mConsent platform require prior express consent per TCPA requirements. Please do not enter patient names or any patient health information into this form.
Product claims & Master Service Agreement. Descriptions of mConsent capabilities reflect how the platform is designed to behave in typical configurations and are not guarantees of any specific result. Features, plan inclusions, pricing, and availability are subject to the terms of your Master Service Agreement.
Integrations & trademarks. mConsent is designed to work with Dentrix, Eaglesoft, Open Dental, and other major PMS. Available capabilities depend on your PMS product and version, network configuration, and workflow setup. Dentrix and Dentrix Ascend are trademarks of Henry Schein One, LLC. Eaglesoft, Dolphin, and OfficeMate are trademarks of Patterson Dental Supply, Inc. Open Dental is a trademark of Open Dental Software, Inc. HIPAA is a United States federal statute; no trademark or endorsement by the U.S. Department of Health and Human Services is implied. Third-party marks identify the systems mConsent integrates with and do not imply endorsement, affiliation, or sponsorship.
