Health Insurance Portability and Accountability Act



Link to Privacy Practice Consent pdf file

Current Notice of Privacy Practices


Stateline Oral & Maxillofacial Surgery, PC

Consent for the use of Private Health Information


Our office operates in compliance with the United States Governments’ Health Insurance and Accountability Act (HIPAA).  To that end, we are required to establish policies that manage the distribution of personal health information (PHI).  As a patient, you are required to consent to the professional use of PHI.  Our office staff would be happy to answer any questions that you might have regarding our policies.

Our office reserves the right to change these policies in accordance with government standards.  You may request an updated “Notice of Privacy Practices” at any time; patients of record will not be automatically informed of these changes.


Patient / Guardian affirmation:

As a patient of Stateline Oral & Maxillofacial Surgery, PC, I understand that my personal health information (PHI) may be used for treatment, payment or health care operations.  A written policy regarding the use of PHI by this office is available at my request.

As a patient of Stateline Oral & Maxillofacial Surgery, PC, I do have the right to request that the use of my PHI be restricted.  I understand that my request must be submitted in writing.  If the practice of Stateline Oral & Maxillofacial Surgery, PC agrees to said restrictions, they will become binding.

As a patient, and in accordance with governmental policies, I may revoke this consent at any time.


Link to General Information regarding HIPAA


Wisdom tooth surgery
Implant surgery
Consent Forms
Professional links