Home Dental FormsConsent And Disclosure


Consent of the Use and Disclosure of Protected Health Information for Treatment, Payment or Health Care Operations.

I understand that as part of my health care, Dr. Zoltan Rusznak DDS PC creates and maintains health records containing information about my individual health history, symptoms, examination and test results, diagnoses, treatments provided to me, plans for future care or treatment, and payment for care provided to me. I understand that this information serves as:

  • A basis for planning my care and treatment
  • A means of communication among the many health professionals who contribute to my care
  • A source of information for applying my diagnosis and treatment information to my bill and seeking payment for the services rendered to me.
  • A means by which a third-party payer can verify that services billed were actually provided.
  • A tool for routine health care operations, such as assessing quality and reviewing the competence of health care professionals.

I understand and have been or will be provided with written Notice of Privacy Practices that provides more complete description of information uses and disclosures. I understand that I have the right to review this Notice of Privacy Practices prior to signing this Consent. I understand that the dental practice reserves the right to change its Notice of Privacy Practices to reflect changes in the way it handles health records, and that I have the right to request a copy of such new Notice.

I understand that I have the right to:

  • Request Restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations. The dental practice is not required to agree to the restrictions requested, but that will be bound by any restrictions it does agree to.
  • Revoke this consent in writing, except to the extent that the practice has already taken action in reliance thereon. I understand that if I revoke my consent, that the dental professional will no longer be able to treat me.

Date: October 23, 2017