Form: Notice of Privacy Practices

Patient Information

Building Functional Esthetics

2131 Hudson Ave

Kalamazoo, MI 49008

Phone: 269-344-8988

Notice of Privacy Practices and Patient Consent

For Use and Disclosure of Protected Health Information

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain Patient Rights regarding my protected health information.

I understand that Building Functional Esthetics/Mark A Allen DDS, PC may use or disclose my protected health information for treatment, payment or health care operations—which means for providing health care to me, the patient; handling billing and payment; and, taking care of other health care operations. Unless required by law, there will be no other uses and disclosures of this information without my authorization.

Building Functional Esthetics/Mark A Allen DDS, PC has a detailed document called the ‘Notice of Privacy Practices’. It contains a more complete description of your rights to privacy and how we may use and disclose protected health information.

I understand that I have the right to read the ‘Notice’ before signing this agreement. If I ask, Building Functional Esthetics/Mark A Allen DDS, PC will provide me with the most current Notice of Privacy Practices.

My signature below indicates that I have been given the chance to review such copy of the Notice of Privacy Practices. My signature means that I agree to allow Building Functional Esthetics/Mark A Allen DDS, PC to use and disclose my protected health information to carry out treatment, payment, and health care operations. I have the right to revoke this consent in writing at any time, except to the extent that Building Functional Esthetics/Mark A Allen DDS, PC has taken action relying on this consent.


You may obtain a copy of our Notice of Privacy Practices, including any revisions of our ‘Notice’ at any time by contacting: Building Functional Esthetics, 2131 Husdson Ave, Kalamazoo, Mi 49008, 269-344-8988, Fax: 269-344-2565 information also posted on our Website @ kalamazoodds.com.

Patient or Legal Guardian/Authorized Representative

Sign Form

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.