NEWPORT BEACH DENTAL CENTER

Jafar Assaf, DDS

Gina Assaf, DDS

1441 Avocado Ave, Ste 606 Newport Beach, CA 92660

AUTHORIZATION AND ACKNOWLEDGEMENTS

Authorizations and Acknowledgements

ACKNOWLEDGEMENT OF PRIVACY PRACTICES AND CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Private Practices: I (the patient) have the right to read the Privacy Practices. A copy of the Notice and/or this consent is available upon request and anytime on our website. The Notice provides a description of our practice’s treatment, payment activities, healthcare operations and the uses and disclosures we make of your protected health information.

Purpose of Consent: I (the patient) understand and consent to the use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.

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