HIPAA Consent for Use and Disclosure of Health Information

What I am authorizing

I authorize Esthetique Dentistry of Ashburn to use and disclose my protected health information for the purposes of treatment, payment, and healthcare operations, including sharing information with my dental benefit plan and with other healthcare providers involved in my care.

Any such use or disclosure will be limited to the minimum information necessary for the purpose, except where the disclosure is to another provider for treatment.

The Notice of Privacy Practices

I understand that the practice's Notice of Privacy Practices describes these uses and disclosures in full, together with my rights, and that I have been given the opportunity to read it.

Revoking this authorization

I may revoke this authorization in writing at any time by contacting the practice, except to the extent the practice has already acted in reliance on it. Revoking it will not affect information already disclosed while it was in effect.

What this does not cover

This authorization does not permit the practice to use my health information for marketing, or to sell it. Those require a separate written authorization, and I may decline without affecting my care.