2322 196th St. SW, Suite 201 Lynnwood, WA 98036
Airway Centered Expert in Lynnwood near Bothell, Mill Creek, Brier, and Mountlake Terrace
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During my treatment with Dr. David Buck & Balance Epigenetic Orthodontics, I acknowledge confidentiality is an important component of privacy. Patients share some of their most sensitive personal information with their physicians and physicians, in turn, have an obligation to ensure the information entrusted to them is kept secure and confidential.
Dr. David Buck & Balance Epigenetic Orthodontics recognizes that the internet provides unique opportunities to participate in interactive discussions and share information on particular topics using a wide variety of social media, such as Facebook, Twitter, blogs, and wikis. However, patients' use of social media can pose risks to Dr. David Buck & Balance Epigenetic Orthodontics’ confidential and proprietary information and reputation and can jeopardize our compliance with medical practice laws.
Posting any pictures directly related to your treatment and any pictures taken in Dr. Buck’s office is strictly prohibited. If this is violated Dr. David Buck & Balance Epigenetic Orthodontics may terminate any and all further treatment with you as a patient.
Discussing your treatment on social media, in our experience, produces unnecessary worry, fear, doubt and potentially hysteria which all undermine our provider-patient relationship. Treatment questions, concerns, problems or uncertainties must be addressed to Dr. Buck and/or office team and must not be posted to any social media.
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. Conversations within our office between providers, administrative staff and patients may be recorded for training and/or quality of care purposes.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our notice provides a description of our treatment, payment activities, and healthcare operations of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this consent. We encourage you to read it carefully and completely before signing this consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy practices, including any revisions of our Notice, at any time by contacting:
Contact Person: Dr. S. David Buck Phone number: (425)-361-7499 Address: 2322 196th Street SW Suite 201, Lynnwood, WA. 98036
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this consent before we received your revocation, ad that we may decline to treat you or to continue treating you if you revoke this consent. I have had the full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.
If this consent is signed by a personal representative on behalf of the patient, complete the following:
