(Patient’s name) understand that as part of my health care,
Century City Smiles, originates and maintains health records describing my health history, symptoms,
examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that
this information serves as:
- a basis for planning my care and treatment
- a means of communication among the health professionals who may contribute to my health care;
- a source of information for applying my diagnosis and surgical information to my bill;
- a means by which a third-party payer can verify that services billed were actually provided;
- a tool for routine health care operations such as assessing quality and reviewing the competence of
health care professionals
I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description
of information uses and disclosures.
I understand that as part of my care and treatment it may be necessary to provide my Protected Health
Information to another covered entity. I have the right to review Century City Smiles notice prior to signing this
authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes
and to the parties designated by me.