Richard S. Berk, DDS & Allan B. Klein, DDS, PC
Oral & Maxillofacial Surgeon
3377 Richmond Avenue, Staten Island, NY 10312
718-948-2900
Uses and Disclosures of Protected Health Information.
I understand that my protected health information may be used and
disclosed by Drs. Berk and Klein and their office staff and others
outside of the office that provide health care services to me, handle
billing and payment and support the day-to-day health care operations
of the practice, and any other uses required by law.
Requesting a Restriction.
I may request a restriction on the uses and disclosure of my protected
health information or cancel the request at any time. I understand
that Drs. Berk and Klein may or may not restrict the use and disclosure
of my protected health information. If Drs. Berk and Klein agree to my
request, the restriction will be binding on the practice of Drs. Berk
and Klein. The use and disclosure of this information will be a
violation of the federal privacy standards.
Revocation of Consent.
I may revoke this consent at any time and it must be in writing. Any
use or disclosure that has already occurred, prior to the date on which
my revocation or consent is received, will not be affected. If I
cancel this consent, Drs. Berk and Klein and their staff do not have to
provide any further health care services to me.
Reservation of Right to Change Privacy Practice.
Drs. Berk and Klein have the right to modify the privacy practices
outlined in this consent.
My doctor has a detailed document called “The Notice of Privacy Practices.” It contains more information about the policies and practices protecting my privacy. I understand that I have the right to read this “Notice” before signing this agreement. I am also entitled to receive a copy of the most recent “notice of Privacy Practices” and this “Notice” will always be posted at my doctor’s office.
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