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I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used, but is not mandatory for me to sign in order to: Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly, obtain payment from third-party payers, conduct normal healthcare operations such as quality assessments and physician certifications. I have received a copy of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given a copy of your Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree than you are bound to abide by such restrictions.I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.
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Last
I authorize Valley Dental to disclose my dental information to the individuals listed below:
First Name
Last Name
Relationship
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Relationship to Patient:
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Welcome
The Valley Dental Team
New Patients
About You Form
Patient Medical History
Patient Registration Form
Office Financial Policy
Patient Consent Form
Financing
Contact Us
Valley Dental
1637 Main St
Onalaska, WI 54650
Phone:
(608) 781-3999