I understand that as part of my healthcare, Chesterfield Family Dental, LLC, originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, billing information and any plans for future care of treatment. I understand that this information serves as:
I understand and have been provided with a NOTICE OF PRIVACY PRACTICES that provides a more complete description of information uses and disclosure. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change its notice and practices and will provide a copy of any revised notice. I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that organization has already taken action reliance thereon.
I have the right to request restrictions on the use of my health information. I understand that my request is not agreed to by Chesterfield Family Dental, PC, unless it agrees to the request in writing