I acknowledge that I have been offered a copy of the Statement of Privacy Practices for the office of Patrick J. McCoy, DDS. The Statement of Privacy Practices describes uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office healthcare operations. The posted Statement of Privacy Practices describes my rights and the responsibilities of this office with respect to my protected health information.
Patrick J. McCoy, DDS reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If changes occur I will be offered a revised copy at the first visit after the revision is made.
In addition to the allowable disclosures described I authorize disclosure of my protected health information to the persons indicated below.