Privacy Policy

Dear Valued Patient / Family of Patient of Snyder & Dugan Oral and Maxillofacial Surgery:

The United States government has passed a law that requires us to clearly identify guidelines for release of medical information. This law took effect on April 14, 2003. The purpose of this law is to safeguard medical information from sources not authorized to posses this information and at the same time to release appropriate information to other healthcare providers, insurance companies and other authorized agencies.

You have the right to request restrictions on the use and disclosure of your health information. You also have the right to inspect and / or copy your health information. We may charge you a reasonable charge to cover copying, etc.

An expanded document is available upon request, which covers these issues in greater detail. If you would like a copy of this document, please let our office staff know and we will be happy to provide it to you.

Sincerely,

Snyder & Dugan Oral and Maxillofacial Surgery


I have read the above and understand my rights under these new regulations

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Patient Name                                                  Date

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Responsible Party Signature

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Relationship to Patient






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