St. Augustine Oral & Facial Surgical Center

This notice describes how Medical/Protected Health Information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Summary: By law, we are required to provide you with our Notice of Privacy Practices (NPP). This Notice describes how your medical information may be used and disclosed by us. It also tells you how you can obtain your information.

As a patient, you have the following rights:

1. The right to request and copy your information;
2. The right to request corrections to your information;
3. The right to request your information to be restricted;
4. The right to request confidential communication;
5. The right to report of disclosures of your information; and
6. The right to a paper copy of this notice.

We want to assure you that your medical/protected health information is secure with us. This notice contains information about how we will insure that your information remains private.

If you have any questions about this notice, please contact our office, at 904-460-0505.

Acknowledgement of Notice of Privacy Practices

“I hereby acknowledge that I have received a copy of this practice’s Notice of Privacy Practices. I understand that if I have any questions or complaints regarding my privacy rights that I may contact the office number listed above. I further understand that the practice will offer me updates to the Notice of Privacy Practices should it be amended, modified, or changed in any way.”

You may authorize certain individuals to be involved in your care. This consent for disclosure includes both health and financial information as it relates to your care. Below you may list those individuals for which our office is allowed to release your Protected Health Information.

Please sign below to show that you are aware that our office does not honor Advance Directives. However, if you would like a Living Will Statement, please request a copy from a staff member.