I, as the parent or legal guardian for the above stated child understand that as part of my heath care, Dr. L. Ruth Berry, D.M.D., P.A. originates and maintains paper and/or electronic records describing my health history, symptoms, examinations, and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:
- A basis from planning my care and treatment.
- A means of communication among the dental professionals who contribute to my care, such as referrals.
- A source of information for applying my disagnoses and treatment information to my bill.
- A means which a third-party can verify that services billed were actually provided.
- A tool or routine operations, such as assessing quality reviewing the competence of staff.
I have been provided with a Notice of Patient Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
- The right to view Notice prior to signing this consent
- The right to restrict or revoke the use or disclosure of my health information for other uses or purposes, and
- The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations, treatment, payment.