Health MattersRelated to Periodontal Disease
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Articles of interest in Periodontics
Consent for Purposes of Treatment, Payment and Healthcare Operations
I consent to the use or disclosure of my protected health information by Aymee or Steven Spindler, D.D.S. for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Aymee or Steven Spindler, D.D.S.. I understand that diagnosis or treatment of me by Aymee or Steven Spindler, D.D.S. may be conditioned upon my consent as evidenced by my signature on this document.
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Aymee or Steven Spindler, D.D.S. is not required to agree to the restrictions that I may request. However, if Aymee or Steven Spindler, D.D.S. agrees to a restriction that I request, the restriction is binding on Aymee or Steven Spindler, D.D.S.
I have the right to revoke this consent, in writing, at any time, except to the extent that Aymee or Steven Spindler, D.D.S. has taken action in reliance on this consent.
My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I understand I have a right to review Aymee or Steven Spindler, D.D.S.'s Notice of Privacy Practices prior to signing this document. The Aymee or Steven Spindler, D.D.S.'s Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of the Aymee or Steven Spindler, D.D.S. The Notice of Privacy Practices for Aymee or Steven Spindler, D.D.S. is also provided in a framed copy located in the patient reception area and on the Spindler, Periodontal Specialist's website at http://www.spindlerperio.com./ This Notice of Privacy Practices also describes my rights and the periodontist's duties with respect to my protected health information.
Aymee or Steven Spindler, D.D.S. reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by accessing the Spindler Periodontal Specialist's website, calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
Description of Personal Representative's Authority