Protected Health Information (“PHI”) may include information/documents regarding dental treatment of the patient including, but not limited to, diagnosis, procedures, treatment plans, appointment, account and billing information including, but not limited to, account balances, payments and payment arrangements, insurance claims status, and third party financing.
I understand that the Health Insurance Portability and Accountability Act of 1996, and its implementing regulations (“HIPAA”) govern the terms of this Authorization. I understand that I have the right to revoke this Authorization, at any time prior to the Practice’s compliance with the request set forth herein, provided that the revocation is in writing. I further understand that additional information relating to the exceptions, the right to revoke and a description of how I may revoke this Authorization is set forth in DDA’s Notice of Privacy Practices. I understand that any revocation must include my name, address, telephone number, date of this Authorization and my signature; and that I should send it to the attention of the “HIPAA Compliance Officer”.
I understand that I am not required to sign this Authorization and that DDA may not condition treatment on my execution of this Authorization.
I understand that the information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the Recipient listed above and, in that case, will no longer be protected by HIPAA.
This authorization expires when I am no longer a patient in this practice or have revoked this authorization.