Our commitment at Precision Endodontics is to serve our patients with professionalism and care, being sure at all times to protect the privacy and security of all Protected Health Information.

During the course of serving your interests, it may be necessary to share information with other Health Care Providers. The following are examples of instances where information may be shared:

● During treatment we may find it necessary to obtain information from your referring Dentist that would assist us in your treatment.

● To obtain payment for services we provide to you.

● During health care operations, we may need a second opinion.

We may use or disclose your information to provide you with appointment reminders such as voicemail messages, postcards or letters.

You have the right to look at or get copies of your health information. We will not charge you any additional fee for such a request.

We are committed to obeying all Federal, State and Local laws and regulations regarding Privacy Practices. If any other uses or disclosures than the ones listed above are needed, information will only be released with the written authorization of the individual in question. The individual, as provided for by law, may revoke this written authorization at any time.

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 below. Please understand that revocation of this Consent will not affect any action we took in reliance on 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

I have had full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices. I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment I have had full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices. I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment. I have read and understood the Notice of Privacy Practices.