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We cannot give it retroactive effect, so it will not affect any use or disclosure that occurred in our reliance on your Consent or Authorization prior to revocation (i.e.if after we provide services to you, you revoke your authorization / acknowledgement in order to prevent us billing or collecting for those services, your revocation will have no effect because we relied on your authorization/ acknowledgement to provide services before you revoked it).If you have any questions about this Notice, please ask to speak to our HIPAA Privacy Officer.Our doctors, clinical staff, employees, Business Associates (outside contractors we hire), their subcontractors and other involved parties follow the policies and procedures set forth in this Notice.PLEASE REVIEW IT CAREFULLY For purposes of this Notice “us” “we” and “our” refers to the Name of this Healthcare Facility: Mc Clure Pediatric Dentistry and “you” or “your” refers to our patients (or their legal representatives as determined by us in accordance with state informed consent law).When you receive healthcare services from us, we will obtain access to your medical information (i.e. We are committed to maintaining the privacy of your health information and we have implemented numerous procedures to ensure that we do so.– You will be asked to sign an Authorization / Acknowledgement form when you receive this Notice of Privacy Practices.If you did not sign such a form or need a copy of the one you signed, please contact our Privacy Officer.
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You may take back or revoke your consent or authorization at any time (unless we already have acted based on it) by submitting our Revocation Form in writing to us at our address listed above.