Heber Valley Oral & Maxillofacial Surgery and its employees are hereby authorized to collect medical history information, obtain vital signs and perform other routine procedures for procedures for purposes of providing care to you. You have the right to consent or refuse consent to any proposed procedure or therapeutic course, absent emergency or extraordinary circumstances. Under emergency circumstances, we will take necessary and available actions to meet your medical needs.
CONSENT TO DISCLOSURE OF INFORMATION
Patient medical records and billing information are created and retained by Heber Valley Oral & Maxillofacial Surgery and are accessible to its personnel and medical staff for use in patient care. Heber Valley Oral & Maxillofacial Surgery personnel and physicians may use and disclose medical information for its business operations and to any other physician or health care personnel involved in providing care. Safeguards are in place to discourage improper access. Heber Valley Oral & Maxillofacial Surgery is authorized to disclose all or part of the patient’s medical record to any insurance carrier, workers compensation carrier, or administrator of a self-insured employer group which is responsible for any part of Heber Valley Oral & Maxillofacial Surgery’s charges and to any health care provider who is or is expected to become involved with a patient’s care. These disclosures are for treatment or payment purposes. Utah law requires that we advise you that the information authorized for disclosure may include information which may be considered a communicable or venereal disease, including, but not limited to, Hepatitis, Syphilis, Gonorrhea, Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (AIDS). You may revoke this consent in writing addressed to Heber Valley Oral & Maxillofacial Surgery, except to the extent we have already acted in reliance on it.