This notice describes how medical information about you may be used and disclosed and how you can access to this information. Please review it carefully. You will be provided a copy for your future reference.
Federal privacy law permits health care providers and those that assist them to use certain types of patient health information without a patient’s consent. The permitted uses of the information are for providing treatment to the patient (which include disclosures between physicians and/or nurses), for purposes of collecting payment for the treatment from Medicare, Medicaid, private insurers (such as submitting diagnostic information and test results to your insurance company or to a collection agency for non-payment and to a billing company employed by us for the purpose of collecting payment). Health information may also be used for certain health care operations.
Patient health information may be used for other purposes only with written consent of the patient (or the patient’s parent or guardian). It is our policy that we will limit our use of your health information to the purposes described above. Therefore, this is a notice to you of our policies and not a request for permission to use your health information. By signing below, you are merely confirming that you have reviewed and received this document.
Federal law permits patients to examine their medical records once each calendar year at no cost to the patient. Patients may be charged for additional requests during the same calendar year. If a patient believes the medical records contain inaccurate information, the patient is permitted to ask that the records be corrected. We will investigate any claim of inaccuracy and make any corrections where warranted. If you wish to examine your medical records in the possession of a hospital, physician, home health agency or durable medical equipment supplier, you must contact them directly.
If you wish to review your medical records in our possession, the request must be in writing. You may request a form for that purpose by writing or calling:
Eisner Oral Surgery Center
11020 N. Kendall Dr., Ste. 106
Miami, Fl. 33176
I hereby acknowledge that I have read the above notice and have been given a copy of this notice.
Print patient’s name Patient’s signature & Date
**IF PATIENT IS UNDER THE AGE OF 18 PARENT/GUARDIAN MUST SIGN**
(PRINT AND BRING TO YOUR FIRST APPOINTMENT)