Minneapolis Dental 150 South 5th Street, ste 1475 Minneapolis, MN 55402
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to
comply with this restriction.
I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure
that occurred prior to the date that I revoke this consent is not affected.