I understand that the Notice of Privacy Practices from Venetia Laganis D.D.S, M.S defines more information regarding the use and disclosure of my protected health information as well as my rights to my health information.
By signing this, I ackowledge that Dr. Venetia Laganis, D.D.S, M.S has offered me a copy of their Notice of Privacy Practices.
I acknowledge and understand the rights that I have over my protected health information.
I authorize the use and disclosure of my protected health information as specified in the Notice Of Privacy Practices.
I authorize the use and disclosures for treatment, payment, and healthcare operations purposes for Venetia Laganis, D.D.S, M.S.
I authorize Venetia Lganis, D.D.S,M.S to communicate regarding my dental treatments to the following individual(s):