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PURPOSE: This form is to obtain an individual’s permission for our use of the individual’s patient health care records to carry out treatment, payment activities, and health care operations. This consent is a condition of your treatment by us. If you choose not to sign this consent, we may decline to treat you. You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of uses and disclosure of your protected health information (PHI) and of other important matters about your protected health information.

In signing this HIPAA patient acknowledgment and consent form, you acknowledge and authorize that this office may recommend products or services to promote your overall health. This office may or may not receive third party remuneration from these affiliated companies. We under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.


We also use this form to ask you how you would like to be addressed in the reception area and other areas of public accommodation in our office. We also ask who you would like to share this information with.


Online Payment

You can make online payments via Mastercard, Visa, Discover and eChecks.

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Payment Plans

Jefferson Dental Center offers a variety of payment plans including Care Credit and in-house payment plans. More information can be found on our Payment Plan Options page.

© 2022 Jefferson Dental Center, Inc. located in South Bend, Indiana.

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