Dr. David Lenhart
Dr. Sydney Sherman
(419) 882-6970
lenhartorthodontics.com

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Benefits

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: PATIENT INFORMATION
SECTION B: TO THE PATIENT—PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities, healthcare operations, of the uses and disclosures we may make of your protected information and of other important matters about your protected health information. You may request to see a copy of our Notice of Privacy Practices.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our notice, at any time by contacting:
Contact Person:
David M. Lenhart DDS MSD
Telephone:
(419) 882-6970
Fax:
(419) 882-1928
E-mail:
N/A
Address:
4323 N Holland Sylvania Rd Toledo, OH 43623
Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance to this consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this consent.

SIGNATURE

Reproduction and use of this form by dentists and their staff Is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.