My signature authorizes Mashpee Orthodontics, P.C. to release any medical or other information for purposes such as treatment, payment or health care operations. I authorize payment of benefits directly to Mashpee Orthodontics, P.C..
I understand that, under Health Insurance Portability & Accountability Act 1996 ("HIPPA"). I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
I understand that I may request that you restrict how my private inforation is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my restrictions but if you do agree then you are bound to abide by such restrictions.