Please indicate if you have had in the past or present Y (yes) or have not had N (no) to any of the following:
To the best of my knowledge, all of the preceding answers are true and correct. If I have change in my health or if my medications change, I will inform the doctor at the next appointment without fail.
Our practice understands the importance of privacy and is committed to maintaining the confidentiality of your medical/dental information. We make a record of the dental care we provide and may receive similar records from other sources. We use these records to provide or enable other health care providers to provide quality dental care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this dental practice properly.
We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information.