Notice of Privacy Practices

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain Patient Rights regarding my protected health information.

I understand that Brit Phillips DDS, PA may use or disclose my protected health information for treatment, payment or health care operations - which means for providing health care to me, the patient;handling billing and payment; and, taking care of other health care operations. Unless required by law, there will be no other uses and disclosures of the information without my authorization.

Brit Phillips DDS, PA has a detailed document called the 'Notice of Privacy Practices'. It contains a more complete description of your rights to privacy and how we may use and disclose protected health information.

I understand that I have the right to read the 'Notice' before signing this agreement. If I ask, Brit Phillips DDS, PA will provide me with the most current Notice of Privacy Practices.

My signature below indicates that I have been given the chance to review such copy of the Notice of Privacy Practices. My signature means that I agree to allow Brit Phillips DDS, PA to use and disclose my protected health information to carry out treatment, payment, and health care operations. I have the right to revoke this consent in writing at any time, except to the extent that Brit Phillips DDS, PA has taken action relying on this consent.