I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly

Obtain payment from designated third-party payers. (Medical and Dental insurance companies)

Conduct normal health care operations such as quality assessments or evaluations, and physician certifications.

I have been given the right to review such Notice of Privacy that contains a more complete description of the uses and disclosures of my health information.

I understand that I may request in writing that Yates Center Dental restricts how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand Yates Center Dental is not required to agree to my requested restrictions, but if Yates Center Dental does agree, then it is bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that Yates Center Dental has taken action relying on this consent.

I understand that any other parties that I list below can have access to patient's health information up to and including account balances.

By checking the box below I agree that to the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health or change in my medication, I will inform the dentist at the next appointment.

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