JAI H. SHIN, DDS, PLLC
& Associates (AKA Lux Smiles)

1. Fill out information online, print out the completed form, and sign it at our office; or
2. Print out a blank form, fill it out and sign it at our office; or
3. Fill out the forms that we have in the office and sign there.

HIPAA PATIENT COMMUNICATION FORM

Is it the office policy of Jai H. Shin, DDS, PLLC, not to release confidential medical and dental information regarding your treatment to family members or friends except for:

1. Parent/legal guardian;
2. Other persons authorized by the patient;
3. As we may reasonably infer from the circumstances;
4. In emergency situations; or
5. Other as otherwise permitted by Health Insurance Portability and Accountability Act of 1996 (HIPAA).

If you anticipate that you will need or want your medical information to be provided to family members, friend(s) or caretakers/baby-sitters, please indicate that below, so that we may best serve you. By signing below, you authorize the following people to receive information regarding your treatment or care. If you wish to add names later on, please confirm this IN WRITING to our staff.