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HIPAA of 1996
mandates data
privacy and security
for safeguarding
patient’s medical
information.

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FREE Exclusive Access to our

HIPAA Form

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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.

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Mantain complete confidentiality,
integrity, and availability of all
Electronic protected health
information that is created,
received or transmitted.

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Identify and protect
against reasonably
anticipated threats to the
patients information &
security.

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Ensure proper training and complete
compliance by your
workforce.

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mConsent provides 100% HIPAA Compliant
Online Dental Intake Forms.

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Learn how mConsent can help keep your
office HIPAA Compliant

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General HIPAA Privacy
Breaches in Dental Offices

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Not properly maintaining
confidentiality of patient data
via encryption.

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Failing to attain patient
authorization prior to release
of personal information.

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Improper discarding of patient
data via paper forms.

Want to Ensure HIPAA Compliance at your Office?

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FAQs on HIPAA Forms

A HIPAA form provides authorization for particular disclosure of a patient's private health information.

Entities that must abide by HIPAA include health care providers, health plans, and health care clearinghouses.

Common HIPAA violations include a lack of proper data security, data breaches, insufficient employee training on HIPAA rules and regulations, improper disposal of confidential information, and unauthorized disclosure of patient information.

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 is important as it provides covered entities with authorization to use private health information for particular purposes.

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
  • Email
  • Pickup

What Information is Being Disclosed

Indicate the type of information

  • 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
Free Download Updated HIPAA Form 2023

Success Stories

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Grace

Grace

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"Before mConcent everything was definitely more labor intensive, lots of time consuming paperwork that we don't have to do now with mConcent."

ADIRA

ADIRA "DEE" BAILEY

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"Before using mConsent I had to print out the router sheet everyday and get the patient's signature, very time consuming."

Stefanie

Stefanie Daley

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"Before using mConsent we had to find and pull patients' charts and input data, it takes a lot of time."
 

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