I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
-Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly.
-Obtain payment from designated third-party payers.
-Conduct normal health care operations such as quality assessments or evaluations, and physician certifications.
I have been informed by you of your Notice of Privacy Practices that contains a more complete description of the uses and disclosures of my health information (available at the following link HIPAA Notice of Privacy Practices or in office in print form).
I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that Stutler Dental has the right to change its Notice of Privacy Practices from time to time and that I may contact Stutler Dental at any time to obtain a current copy of the Notices of Privacy Practices.
I understand that I may request in writing that Stutler Dental restricts how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand Stutler Dental is not required to agree to my requested restrictions, but if Stutler Dental does agree, then it is bound to abide by such restrictions.
I understand that I may revoke this consent in writing at any time, except to the extent that Stutler Dental has taken action relying on this consent.