Dr. Jerome Yamada Office
Endodontic Specialists



Notice of Privacy Practices
I understand that, under the Health Insurance Portability and 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 among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third party payers.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.
I have been informed by you of your Notice of Privacy Practices, containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that
Endodontic Specialists has the right to change its Notice of Privacy Practices from time to time and that I may contact them at any time at 121-112th Ave NE, Suite B, Bellevue WA 98004 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 health care operations. I also understand that you are bound to abide by such restrictions.
I understand that I may revoke this consent in writing at any time except to the extent that you have taken action relying on this consent.
I authorize Endodontic Specialists to leave messages for me on my voicemail at home or at work regarding my visit and treatment.

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