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(337) 704-2126 1601 Kaliste Saloom Rd, Lafayette LA 70508 Schedule an Appointment

Notices of Privacy Practices Acknowledgement

Gina Liggio Maestri, D.D.S.
1601 Kaliste Saloom Rd
Lafayette, LA 70508
Consent to the Use and Disclosure of Health Information
for Treatment, Payment, or Healthcare Operations

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

  • a basis for planning my care and treatment
  • a means of communication among the many health professionals who contribute to my care
  • a source of information for applying my diagnosis and surgical information to my bill
  • a means by which a third-party payer can verify that services billed were actually provided
  • and a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I’ve provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon.

  • Date Format: MM slash DD slash YYYY
Maestri Family Dental Logo

welcome

Welcome to exceptional family dentistry in Lafayette. Dr. Gina Liggio Maestri DDS and her team of dedicated dental professionals are here to provide you and your family with a level of caring clinical excellence you’ve never experienced before. From our state-of-the-art technology to our many comfort amenities, we have everything you need to feel relaxed while you enjoy gentle dentistry in Acadiana.

find us @

1601 Kaliste Saloom Road
Lafayette, LA 70508

337-704-2126

Maestri Family Dental Logo

welcome

Welcome to exceptional family dentistry in Lafayette. Dr. Gina Liggio Maestri DDS and her team of dedicated dental professionals are here to provide you and your family with a level of caring clinical excellence you’ve never experienced before. From our state-of-the-art technology to our many comfort amenities, we have everything you need to feel relaxed while you enjoy gentle dentistry in Acadiana.

find us @

1601 Kaliste Saloom Road
Lafayette, LA 70508

337-704-2126

© Gina Liggio Maestri, DDS Family Dentistry 2019

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