This notice describes how protected health information about you or your child may beused and disclosed to carry out treatment, payment and healthcare operations and how you can get access to this information. Please review it carefully.Uses and disclosures of health informationWe use and disclose health information about you for treatment, payment and healthcareoperations. Your protected health information (i.e., individually identifiable information, such as medical and dental histories, names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:
Any other uses or disclosures of your protected health information will be made only afterobtaining your written authorization, which you have the right to revoke.Patient rights - Under the new privacy rules, you have the right to:
Our legal duty - We have the following duties under the privacy rules:
Please note that we are not obligated to:• Honor any request by you to restrict the use or disclosure of protected health information;• Amend your protected health information if, for example, it is accurate and complete.• Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.This privacy notice is effective as of the date of your signature on the acknowledgement of receipt of this notice. If you have any questions about the information in this notice, please askContact Person or contact Get It Straight Orthodontics, PC.Patient's Name: First Name, Middle Initial, Last Name Date: Date*Signature of Patient: Signature Signature of Parent or Legal Guardian if the patient is a minor: Signature Print Name of Parent or Legal Guardian: First Name, Middle Initial, Last Name