Privacy Consent Form We have a secure server and it is safe to send us the information requested in these forms. Quinn Privacy Consent Section A: Patient/Guardian Giving Consent Patient or Guardian Name * Address City State Zip Phone * Section B: To Patient/Guardian - Please Read Carefully 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: You have the right to read our Notice of Privacy Practices before you decide whether 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 information, and of other important matters about your protected health information. A copy is available upon request. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practice, which will contain the changes. You may obtain a copy of our Notice of Privacy Practices, including any revisions, at any time by contacting: Quinn Dental, P.A. 3938 Cedar Grove Pkwy. Eagan, MN 55122, (651)452-9660 Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of you revocation submitted to our address listed above. Please understand that revocation of this Consent will not effect 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 you revoke this Consent. YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT. PLEASE ADVISE US IF YOU WANT A COPY. I have received acknowledgement of this office’s Notice of Privacy Practices and agree to them. Yes No Your Name * Date * By entering your name and date above and clicking Submit, you acknowledge receipt of and agreement with this office's Notice of Privacy Practices.