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:
- A basis for planning my care and treatment;
- A means of communication among the many health professions who contributes to my care;
- A source of information for applying my diagnosis and dental information to my bill;
- A means by which a third party payer can verify that services billed were actually provided; and
- A means by which payment for services can be made.
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