HIPAA Privacy Regulations
- I hereby authorize this office and any of its employees to use or disclose my Patient Health information to the following person(s), entity(s), or business of this office: Mountain State Endodontics.
- Patient Health Information authorized includes but not limited to: Insurance information, clinical charting, electronic health record, medical history, and imaging. Effective Dates for this authorization: One year from date signed unless otherwise notified.
- I understand that the information disclosed above may be re-disclosed to additional parties and no longer protected for reasons beyond our control.
- I understand I have the right to:
- Revoke this authorization by sending written notice to this office and that revocation will not affect this office’s previous reliance on the uses or disclosure pursuant to this authorization.
- Knowledge of any remuneration involved due to any marketing activity as allowed by this authorization, and as a result of this authorization
- Inspect a copy of Patient Health Information being used or disclosed under federal law.
- Refuse to sign this authorization.
- Receive a copy of this authorization.
- Restrict what is disclosed with this authorization
I also understand that if I do not sign this document, it will not affect my treatment, payment, enrollment in a health plan, or eligibility for benefits whether or not I provide authorization to use or disclose protected patient health information.