Florida Facial Surgery Center, James Gift D.D.S. – AUTHORIZATION FOR THE USE OR DISCLOSURE OF HEALTH INFORMATION

As part of your healthcare, this practice originates and maintains paper and/or electronic records describing your health history, symptoms, examinations, test results, diagnoses, treatment, any plans for future care or treatment, and payment for the services or treatment we provided. We use this information to:

• Plan your care and treatment

• Communicate with other health professionals or entities who contribute to your healthcare

• Submit your diagnosis and treatment information for payment for the services or treatment provided to you.

“ONLY AS PERMITTED OR REQUIRED BY FEDERAL OR STATE LAW”, WE MAY USE YOUR PROTECTED HEALTHCARE INFORMATION TO DO THE FOLLOWING:

• To disclose, as may be necessary, your health information (including HIV+/AIDS status, drug/alcohol abuse/dependency notes and qualified mental health notes) to other healthcare providers and healthcare entities (such as: referrals to or consultation with, other healthcare professionals, laboratories, hospitals, etc.) or to others as may be required by law or court order concerning your treatment, payment and/or healthcare.

• To request from other healthcare entities and/or healthcare providers (i.e. doctors, dentists, hospitals, labs, imaging centers, etc.) specific healthcare information we may need for planning your care and treatment.

• To submit the necessary information to your insurance company(s) for coverage verification as well as the diagnosis and treatment information to your insurance company(s), other agencies and/or individual(s) for payment of our services or treatment we provided you.

• To leave appointment reminders or other minimum necessary information related to your healthcare or healthcare payments on an answering machine, mobile voice or text mail, email or with a household family member.

• To discuss your health or payment information (only the minimum necessary in our judgment) with family members or other persons who are or may be involved with your healthcare treatment or payments.

• You may request a copy of and you have the right to read our “Notice of Patient Privacy Practices” prior to signing the authorization. The NPP provides a more complete description of health information uses and disclosures.