NOTICE OF PRIVACY
This notice describes how your health information may be used and disclosed and how you can
access this information.Please review it carefully. EFFECTIVE AS OF APRIL 14, 2003.
At Steven J. Feldman, DDS we always keep your health information secure and confidential. A new law requires us to continue maintaining your privacy, to give you this notice and to follow the terms of this office.
Do we have your permission regarding.
Personal Health Information(PHI): / May we use or disclose your health information:
We will use whatever address or telephone number you prefer.
I also understand that by refusing to sign or revoking this consent/notice, Steven J. Feldman, D.D.S, P.A.
may refuse to treat me as permitted by Section 164.520 of the Code of Federal Regulations.