Our state-of-the-art dentistry will help you achieve your perfect smile.

Consent for Use and Disclosure of Health Information

Taos Dental Group
Justin Nylund, D.D.S.
Walter Jakiela, D.D.S., M.A.G.D.
C. Tom Simms, D.D.S.

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
Patient Name: __________________________________________
Patient Birth Date: _______________________________________
Purpose of Consent: By signing this form, you will consent to use and disclose 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 to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we make of your protected health information, and of other important matters about your protected health information. A copy of our Notice can be requested by you at the front desk.
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 Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
Contact Person: Justin Nylund, D.D.S.        (575) 758-8654
Right to revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact person listed above. Please understand the revocation of this Consent 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 continue treating you if you revoke this Consent.
I, ______________________________________________________, have had full opportunity to read and consider the contents of this Consent form and Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations.
__________________________________________________            ___________________
Signature of patient or patient representative/parent                Date

__________________________________________________
Printed name of patient or patient representative/parent

__________________________________________________
Relationship to patient

HIPAA-ACKNOWLEDGEMENT OF RECIEPT
Notice of Privacy Practices

I, ______________________________________________________, have received a copy of this office’s Notice of Privacy Practices.
__________________________________________________            ___________________
Signature of patient or patient representative/parent                Date

__________________________________________________
Printed name of patient or patient representative/parent

__________________________________________________
Relationship to patient

Did Your Know?

According to a study by the Gallop Organization and Consumer Reports, dentists are among the top five most trusted professionals.

What do powdered fruit, talc, honey, dried flowers, mice and lizard livers have in common? They have all been ingredients in ancient toothpaste and powder. Yum.

Attention Chocolate Lovers…Many dentists agree raisins can cause more tooth decay than chocolate. Sticky foods such as raisins and dried fruits can stay on the teeth longer and develop more decay.

According to a study at the University of Connecticut, too much toothpaste early in life is responsible for more than 70% of fluorosis cases (staining or mottling of tooth enamel that develops when children swallow fluoridated toothpaste). Although this problem is only cosmetic, it is recommended children under six only use a pea-sized amount of toothpaste and be reminded to spit it out after brushing.