HIPPA Consent Form HIPPA- Notice of Privacy Practice HIPPA is a federal law developed to provide a standard for the protection of your health information. The purpose of the Notice of Privacy Practice is to explain how Oshins of Smiles may use or disclose your health care information. The Notice also explains the rights that you are guaranteed under HIPAA regulations. Though Oshins of Smiles has always taken great care to protect the integrity and confidentiality of your health care information, we are now required by the HIPAA Privacy Rule to distribute this notice to you and obtain acknowledgment that you have received the Notice. Signing below indicates that you have received the Notice of privacy Practice. I hereby acknowledge that I have received a copy of Oshins of Smiles Notice of Privacy Practices. Permission to Share Medical Information My Medical Information may be obtained and exchanged verbally to: Permission to Bill Your Insurance All professional services rendered are charged to the patient. Necessary forms will be completed by Oshins of Smiles to help expedite insurance carrier payments. However, the patient is responsible for all fees, regardless of insurance coverage. I understand my signature authorizes releasing of the information to the insurer or agency given to Oshins of Smiles for participating health insurance plans. Date: Submit Form Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.