I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights regarding my protected health information. I understand that this information can and may be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly
and Indirectly
- Obtain payment from third-party payers
- Conduct normal healthcare operations such as quality assessments and physician certification
I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses
and disclosures of my health Information.
I understand that this organization has the right to change Its Notice Of Privacy Practices from time to time and that I may contact this organization at any time.
I understand that I may request In writing that you restrict how my private Information Is used or disclosed to carry out treatment, payment or healthcare operations.
I also understand you are not required to agree to my requested restrictions, but If you do agree then you are bound to abide by such restrictions.
In addition, I also understand that by naming a specific person(s) to this acknowledgement that I am giving you permission to
speak to named person(s) in regards to my dental treatment or financial history.