Privacy Policy Form

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Privacy Notice

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Federal Privacy Notice Acknowledgement

Our Federal H.I.P.A.A. Privacy Notice provides information about how we may use and disclose protected health information about you; the patient rights section describes your entitlements under the law. You have the right to review our Notice before signing this Consent. You have the right to revoke this Consent, in writing. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. Our practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (H.I.P.A.A.). By signing this form, you are acknowledging that:

  • Protected health information may be disclosed e.g. for treatment, payment or health care operations per our Federal H.I.P.A.A. Privacy Notice, which you have the opportunity to review.
  • The patient can ask to restrict uses of their information but we are obliged solely to comply within the parameters of the law.
  • The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
  • The Practice may, at its discretion, condition treatment upon the execution of this Consent.
  • The Practice reserves the right to change the Notice based on amendments to federal law.

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If you have questions or concerns, or wish to speak with one of our oral/maxillofacial specialists, then please contact our staff at Santa Rosa Oral Surgery, or set up an appointment by clicking here.