HIPAA Consent Form

Patient First Name:

Last Name:

HIPAA - Notice of Privacy Practices

HIPAA is a federal law developed to provide a standard for the protection of your health information. The purpose of the Notice of Privacy Practices is to explain how Sohn Orthodontics may use or disclose your protected health information. The Notice of Privacy Practices is available for you to view on our website, www.sohnbraces.com, or a copy can be obtained by contacting our office. Signing below indicates that you have the opportunity to review the Notice of Privacy Practices.

I certify that I have had the opportunity to review the Notice of Privacy Practices of Sohn Orthodontics.

Patient/Parent/Guardian E-Signature:

Relationship to Patient:

Sohn Orthodontics, 1370 Washington Pike Suite 104, Bridgeville, PA 15017