I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information.  I understand that this information can and will be used to: conduct, plan and direct my treatment and follow-up with multiple healthcare providers who may be involved in my treatment both directly and indirectly; obtain dental benefit eligibility, benefit details, and payment from third-party payers, and conduct normal healthcare operations such as quality assessments and physician certifications. 

I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information.  I understand that Dr. Bryan E. Sorgen, DDS has the right to change the Notice of Privacy Practices from time to time and that I may contact the office at any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations.  I also understand you are not required to agree to my requested restrictions, but if you do agree than you are bound to abide by such restrictions.