In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services, and to conduct health care operations involving our office.
The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and service provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purpose of payment includes:
our submission of your health information to a billing agent or vendor for processing claims or obtaining payment;
our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment;
our submission of your health information to auditors hired by third-party payers and insurers; and
other aspects of payment described in our
Notice of Privacy Practice
Notice of Privacy Practices
will be updated whenever our privacy practices change. You can get an updated copy here at the office (or from our website).
When you sign this consent document, you signify that you agree that we can and will uses and disclose your health information to treat you, to obtain payment for our services and to perform healthcare operations. You also signify that you have received a copy of our Notice of Privacy Practices.
You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment or healthcare operations, but as described in our Notice of Privacy Practices, we are not obliged to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.
I have this document and understand it. I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. I acknowledge that I have received the Notice of Privacy Practices from (Dr. Mehran Abbassian, DDS).