Oral & Facial Surgery of Mississippi understands that your medical information is personal and we are committed to protecting that information. As our patient, medical records about your health, our care for you, and the services and items we provide to you are created by our staff. By law, we are required to keep your health information private.
However, there are certain ways we will disclose your information:
- For medical treatment
- In emergencies
- To obtain payment
- For research
- To avert a serious threat to health or safety
- For organ and tissue donation
- For workers’ compensation programs
- For appointment reminders
- To run over practice efficiently and ensure all our patients receive quality care
- In response to certain requests arising out of or other disputes
You have certain rights regarding the information we maintain about you. They include the right to:
- Inspect and copy
- An account of disclosures
- Request restrictions
- Request a paper copy of this notice
- Request confidential communications
The Notice of Privacy Practices contains a patient rights section describing your rights under the law. You have the right to review this notice before signing a consent. The terms of the notice may change. If so, you may obtain a revised copy.
You have the right to request that we restrict how protected health information about use is used/disclosed. However, we are not required to agree to this restriction.
By signing this form you consent to our use/disclosure of your health information for treatment, payment or healthcare operations. You do have the right to revoke this consent, in writing, signed by you. However, such a revocation shall not affect any previous use/disclosure of your health information. We provide this form in compliance to the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The patient understands that:
Protected information may be usedmay be used/disclosed for treatment, payment or healthcare operations.
The practice has a Notice of Privacy Practices and the patient may review this notice.
The practice reserves the right to change its Notice of Privacy Policies. The patient has the right to restrict the use of their information but the practice is not required to abide by those restrictions.
- The patient may revoke this consent in writing and all future disclosures will cease.
- The practice may condition treatment upon the execution of this consent.
*** If you feel your rights have been violated you may file a complaint with the practice, by contacting the office manager, or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.