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Master, College of Conscious Sedation American Dental Society of Anesthesiology
Advanced Systemic Health Care through the Mouth
All your dental treatment needs met in one location
Michael A. Starkey, DDS MS and The Team
There is the risk of calling and talking to the wrong party or emailing or writing the wrong address. This happens. It is not done on purpose. It is possible that some persons may pose as a certain party that you have okayed conversations with.There is several ways that the privacy of patient and communication to those you do not want us to communicate can occur. It has yet to happen in our practice but given enough time and interactions it may happen and it could happen to you. By signing this agreement you understand that there is risk of wrong person or enitity being given information you would rather not have. And you must hold us harmless for inadvertent communication or by someone conning us into giving information about you by not being honest or misleading us into thinking the party was authorized to communicate with them.
Initial and Date here____________________________that you accept that Dr. Starkey and his staff will do their best to follow the hipaa rules and guidelines but perfect adherence is not possible in some instances and that you will hold us harmless in such events.
If a photo or model or drawing of your teeth or smile is presented in a professional journal or on a web site or in any other manner. You accept that is okay for us to use that photo. We plan to use no photos of patient face without permission of patient. However, it may be that a picture of patient face somehow gets posted on the internet or elsewhere without your informed consent. We will remove that photo of your face if you do not want it posted. But will hold us harmless.
Again we have never posted a picture without patient's permission nor used patient's full name. But there is always a risk of that happening unintentionally and you accept that removal of the photo and full name as agreeable solution to the problem. You do agree that it is okay for us to use images and models of your teeth and smile without use of face unless you give us permission to use your full face.
Please initial here that you agree to the above and date initialing,_______________________
HIPAA informed consent
This is the section that gives us consent to provide information to certain parties. It is the HIPAA Act.
Also other important information that requires your informed consent and understanding of work to be done along with pre operative instructions and post operative instructions for a more successful more comfortable recovery period.
Also in this section is a listing of patient responsibilities for such things as payment, making and keeping appointments, and taking responsibility for their dental health and prevention. Dr. Starkey and the Dental Team responsibilities are also listed in this section.