Gwen Giannina, D.D.S.,L.L.C.

Consent For Use And DisclosureOf Health Information

Section A: Patient Giving Consent

Name:

Address:

Telephone:

Section B: To the patient- please read the following statements carefully.

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protectedhealth information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice Of Privacy Practices before youdecide to sign this Consent. Our Notice provides a description of our treatment, payment activities,and healthcare operations, of the uses and disclosures we may make of your protected health informationand of other important matters about your protected health information. A copy of our Notice accompaniesthis Consent. We encourage you to read it completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. Ifwe change our privacy practices, we will issue a revised Notice, which will contain the changes. Thosechanges may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice.

Contact Person: Suzanne Smith 201-339-1177 fax-201-339-21201173 Kennedy Blvd. Bayonne, NJ 07002

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice ofyour revocation submitted to the contact person above. Please understand that revocation of thisConsent will not affect any action we took in reliance on this Consent,before we received your revocation,and that we may decline to treat you or to continue treating you if the Consent is revoked.

SIGNATURE

_, have had full opportunity to read and consider the contents of thisConsent form and your Notice of Privacy Practices. I understand that, by signing this form, I am givingmy consent to your use and disclosure of my protected health information to carry out treatment,payment activities and health care operations.

Signature: Date

GWEN GIANNINA, D.D.S.,L.L.C.

Acknowledgement of Receipt ofNotice of Privacy Practices

The Health Insurance Portability and Accountability Act of 1996 requires that health careproviders give patients a copy of the office Notice of Privacy Practices and make a goodfaith effort to obtain acknowledgement of receipt of same. You may refuse to sign thisacknowledgement form.

By signing this form I confirm that I have received a copy of the office Notice of PrivacyPractices.

Print name

Sign name

Date

Written acknowledgement was not obtained.

• Patient refused to sign

• Emergency situation

• Unable to communicate with patient

• Other

GWENGIANNINA, D.D.S..L.L.C.

Informed Consent

Photographs

I understand that photographs, x-rays, and other records may be made during the course

of my examination, treatment, and follow-up care. I give my permission for such items

to be used for purposes of research, education, or publication in professional journals.

Print Patient Name

Patient/Guardian Signature Date

Witness