HIPAA Authorization Form & Patient Consent Form

Patient Authorization for Use and Disclosure of Protected Health Information (HIPAA)

Authorization Purpose

Smile Fund USA and MedAid Financial LLC work in collaboration to assist patients in receiving grants for necessary dental procedures. This authorization permits Smile Fund USA and MedAid Financial LLC to collect, use, and disclose my protected health information for the purpose of applying for a grant to fund the following dental procedure(s):

Authorization Scope

I understand that my health information, including details about the dental procedure I require, may be shared with Smile Fund USA, MedAid Financial LLC, and designated local dental providers who specialize in the specific dental procedure(s) described above. This information will be used only for grant application, screening, and funding purposes and will not be disclosed to any other entities.

Financial Information Privacy

I understand that any financial information (monthly income, savings, etc.) I provide for this grant application will not be sold, shared, or disclosed beyond Smile Fund USA and MedAid Financial LLC. This information will only be used to assess eligibility for the grant and ensure compliance with restricted donations.

Right to Revoke

I understand that I may revoke this authorization at any time by providing written notice to Smile Fund USA and MedAid Financial LLC at the contact information below. However, I understand that any action taken based on this authorization prior to revocation is valid.

Expiration

This authorization will expire one year from the date of my signature or upon completion of the dental procedure for which I am applying for funding, whichever comes first.

Contact Information for Questions or Revocation

Smile Fund USA

Address: 1700 Aviara Pkwy, #130141, Carlsbad, CA 92013

Patient Acknowledgment and Signature

I have read and understand this authorization form. I voluntarily authorize the disclosure of my health information as described above.

Patient Consent Form for Information Sharing and Communication with Dental Providers

Purpose of Consent

This form provides you with information on how Smile Fund USA and MedAid Financial, LLC will use and share your personal and financial information as part of your grant application. By signing below, you consent to the collection, sharing, and use of this information for purposes related to processing your grant application, coordinating with dental providers, and complying with IRS rules for tax-exempt organizations.

Information Disclosure

1. Grant Application Processing

Smile Fund USA and MedAid Financial, LLC may share your information with local dental providers to facilitate your grant application process. These dental providers will conduct an exam, make a diagnosis, and create a treatment plan that includes a cost estimate, which they will share with Smile Fund USA and MedAid Financial, LLC. This information is required to assess your grant eligibility and process any grant awards.

2. Coordination with Dental Providers for Treatment Planning

By signing below, you give proactive consent to the dental provider or dentist conducting your exam to share their findings, treatment plan, and cost estimate with Smile Fund USA and MedAid Financial, LLC. This ensures that the required details are available for grant processing and can help expedite funding approval and distribution.

3. IRS Compliance and Tax-Related Reporting

As a tax-exempt organization, Smile Fund USA must follow IRS regulations regarding the documentation of grant activities. This may include documenting financial information related to grant distributions; however, your personal information will not be shared beyond what is required for IRS compliance.

Privacy Protection

Your personal and financial information will only be shared for grant-related purposes or as legally required. We will not share, sell, or use your information outside these purposes. All information is managed with strict confidentiality and stored securely.

Your Rights

- Right to Withdraw Consent: You may withdraw your consent at any time by contacting Smile Fund USA. Please note that withdrawing consent may affect the ability to process your grant application.

- Right to Access and Amend Information: You have the right to review or amend the information we have on file.

Contact Information for Questions or Concerns

If you have questions about this consent form or your rights, please contact:

Smile Fund USA

Address: 1700 Aviara Pkwy, #130141, Carlsbad, CA 92013

Acknowledgment and Consent

By signing below, you acknowledge that you have read and understood this consent form. You authorize Smile Fund USA, MedAid Financial, LLC, and your selected dental provider to share information as outlined above to support your grant application process.