HIPAA  Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Notice of Privacy Practices:  You have the right to read our Notice of Privacy Practices before you decide whether to sign our HIPAA Consent Form.  Our Notice of Privacy Practices provides a description of our treatment, payment activities, and healthcare operations of the uses and disclosures we may make of your protected health information and of other important matters about your protected health information.

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 that 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 Peter R. Bond, DDS, MS at the address listed above.

Right to Revoke:  You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted our office. 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.