HIPAA Privacy Regulations

As required by the HIPAA Privacy Regulations, this practice may not use or disclose your protected health information except as provided in our Notice of Privacy Practices without your authorization.

  • 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:
  1. 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.
  2. Knowledge of any remuneration involved due to any marketing activity as allowed by this authorization, and as a result of this authorization
  3. Inspect a copy of Patient Health Information being used or disclosed under federal law.
  4. Refuse to sign this authorization.
  5. Receive a copy of this authorization.
  6. 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.