I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain right to privacy regarding my protected health information. I understand that this information can and will be used, but is not mandatory for me to sign in order to:
Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
Obtain payment from third-party payers
Conduct normal healthcare operations such as quality assessments and physician certifications
I have been informed of my Notice of Privacy Practices, containing a more complete description of the uses and discloures of my health information. I have been given a copy of your Notice of Privacy Practices prior to signing this consent. I understand that Aesthetic General Dentistry of Frisco has the right to change its Notice of Privacy Practices from time to time and that I may contact Aesthetic General Dentistry of Frisco to obtain a current copy of the Notice of Privacy Practices.
I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. I also give my permission to take my picture at my inital visit to place in my computer dental records - please let us know if you elect not to have your picture taken when registering.