Privacy and Consent


Caring Family Dentistry
Dr. Jeff O. Johnson
16 Mills Ave Suite 4
Greenville, SC 29605
Patient Acknowledgement and Consent Form for use and disclosure of Protected Health Information (PHI)
Our Notice of Privacy practices provides information about how we may use and disclose protected health information about you and your rights with respect to your health information. By signing this form, you acknowledge that you have been provided with our Notice of Privacy Practices to review.
By signing this form, you also instruct this practice to release your medical and/or financial information according to the criteria listed below:

Medical and/or financial information about me may be released to:

Please indicate if our practice can communicate our Protected Health Information (PHI) as described below: (circle answer for each item)