With my permission, Jai H. Shin, DDS, PLLC ("the Dental Practice") may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to the Dental Practice's Notice of Privacy Practice for a more complete description of such uses and disclosures.
I have the right to review the Notice of Privacy Practices prior to signing this consent. The Practice reserves the right to revise its Notice of Privacy Practices at anytime. The latest revised Notice of Privacy Practice may be obtained by forwarding a written request to the Privacy Officer or by visiting this page.
With my permission, the Dental Practice may call my home or other designated locations and leave a message on voicemail or in person, in reference to any items that assists the Dental Practice in carrying out TPO, such as appointment reminders, insurance items, and any call pertaining to my clinical care, including laboratory results, among others.
With my permission, the Dental Practice may mail to my home or other designated location any items that assists the Dental Practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and/or Confidential.
With my permission, the Dental Practice may email to my personal or other designated email address any items that assists the Dental Practice in carrying out TPO, such as appointment reminder messages and patient statements. I have the right to request that the Dental Practice restrict how it uses or discloses my PHI to carry out TPO. However, the Dental Practice is not required to agree to my restrictions, but if it does, it is bound by this agreement.
By signing this, I am allowing the Dental Practice to use and disclose my PHI for TPO.
I may revoke my consent to writing except to the extent that the Dental Practice has already made disclosures in reliance upon my prior consent.
