• The privacy Rule (part of the Health Insurance Portability and Accountability Act of 1996) became effective April 14th 2001. The Privacy Rule establishes a federal requirement that most doctors, hospitals and other health care providers obtain a patient’s written consent before using or disclosing the patient’s personal health information to carry out treatment, payment, or health care operations. Some examples requiring consent include: phoning in prescriptions, referral appointments, insurance billing, etc. This consent gives health care providers, which have a direct treatment relationship with a patient, permission to use and disclose minimum necessary health information.

    I give Evergreen Dental my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews. I have been informed that I may review Evergreen Dental’s Notice of Privacy Practices (for a more complete description of uses and disclosures) before signing this consent.

    I understand that Evergreen Dental has the right to change their privacy practices and that I may obtain any revised notices at Evergreen Dental.

    I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that Evergreen Dental is not required to agree to the request. If Evergreen Dental agrees to my requested restriction, they must follow the restriction(s).

    I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed.
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