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HIPAA Form

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  • Section A: Patient Giving Consent

  • Section B: TO THE PATIENT - PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

    Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. Notice of Privacy Practices: 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 our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Montini Orthodontics 7520 W. University Ave Ste C Gainesville, FL 32607 352 332-7911 Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this consent.
  • I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations.
  • Date Format: MM slash DD slash YYYY
  • If this consent is signed by a personal representative on behalf of the patient, complete the following:

  • Revocation of Consent

    I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations. I understand that the revocation of my consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my consent.
  • Date Format: MM slash DD slash YYYY

"I highly recommend anyone needing orthodontics - young or old- to check out Dr. Montini. He is professional, friendly, and all about his patients having a good experience. Their facility is beautiful and very kid & adult-friendly!"

— Deb H.

"We could not be more pleased with the work that was done by Dr. Montini on my daughter's teeth. I HIGHLY recommend anyone looking for an orthodontist to look no further than Dr. Montini. He and his staff are wonderful."

— Ardis B.

"Dr. Montini and his staff are simply the best! Look no further if you are searching for a wonderful orthodontist. I couldn't be happier with how my kids are treated and how great the results have been."

— Angela B.

"Absolutely amazing, professional, and fast service. I love how passionate everyone is about helping out the people they see."

— Bobby T.

"Dr. Reid Montini has built a practice that actually makes orthodontist visits 'fun'. From superhero drawings and a video game room, your kids will actually enjoy a doctor's visit. All fun aside, Dr. Montini has true passion in making your entire family's smiles picture perfect. It is a change that will last a lifetime."

— John M.

"Dr. Montini is a warm, personable, highly trained and skilled orthodontist. I have seen truly phenomenal changes he has made in restoring proper bite in even the most difficult of cases. He not only restores the smile nature intended, but improves eating (chewing) and thus digestion, nutritional uptake, and overall health. Dr. Montini is great with kids, too!"

— Amy G.

Dream. Live. Smile.

Dream the possibilities.

Live every moment.

Smile with confidence.


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Montini Orthodontics Logo
Gainesville

7520 W University Ave
Suite C
Gainesville, FL 32607
(352) 332-7911

Ocala

3201 SW 34th Ave #202, Ocala, FL 34474
(352) 237-3366

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