I do hereby consent and authorize:
I understand Valley Orthodontics prefers digital records are sent in a digital format via email whenever possible and that these records may be sent and received from unsecured email sources. I may revoke this authorization at any time
Please send records to:
Valley Orthodontics
2400 Las Gallinas Avenue, Suite 130
San Rafael, CA 94903
Phone: 415-479-2400
FAX: 415-901-2628
Email: smiles@valleyorthodontics.net
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Your protected health information (i.e. individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:
Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.
Under the new privacy rules, you have the right to:
We have the following duties under the privacy rules:
Please note that we are not obligated to:
This Privacy Notice is effective as of the date of your signature. If you have any questions about the information in this notice, please ask for our Privacy Contact Person or direct your questions to this person at our office address Thank you.
PATIENT ACKNOWLEDGEMENT
I hereby acknowledge that I have received and reviewed a copy of this Privacy Notice.