Protecting your private information is our priority.
Your protected health information may be used and disclosed by our staff and others outside of our office that are involved in your care and treatment for the purpose of providing dental care services for you, to pay your health care bills, to support the operation of the doctor's practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your dental care.
Payment: Your protected health information will be used, as needed, to obtain payment for your dental care. (such as pursuing payment from an insurance company)
Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your dentist's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of dental staff, licensing, and conducting or arranging for other business activities. In addition, we may call you by name in the waiting room when your dentist is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as Required By Law, Communicable Diseases: Health Oversight: Abuse or Neglect: food and Drug Administrations requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers Compensation: Inmates: Required Uses and Disclosures: Under the Law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.
Other Permitted and Required Uses and Disclosures will be made only with YOUR consent (or if you are a minor - the consent of a legal parent or guardian), Authorization or Opportunity to Object unless required by law.
I have received this practice's Notice of Privacy Practices (HIPPA FORM) written in plain language. This notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights and the practice's legal duties with respect to my protected health information. The notice includes:
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A statement that this practice is required by law to maintain the privacy of protected health information.
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A statement that this practice is required to abide by the terms of the notice currently in effect.
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Types of uses and disclosures that this practice is permitted to make for each of the following purposes: treatment, payment and health care operations.
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A description of each of the other purposes for which this practice is permitted or required to use of disclose protected health information without my written consent or authorization.
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A description of uses and disclosures that are prohibited or materially limited by law.
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A description of other uses and disclosures that will be made only with my written authorization and that I may revoke such authorization.
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My individual right with respect to protected health information and brief description of how I may exercise these rights in relation to:
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The right to complain to this practice and to the Secretary of HHS if I believe my privacy rights have been violated, and that no retaliatory actions be used against me in the event of such a complaint.
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The right to request restrictions on certain uses and disclosures of my protected health information, and that this practice is not required to agree to a requested restriction.
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The right to receive confidential communications of protected health information.
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The right to inspect and copy protected health information.
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The right to amend protected health information.
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The right to receive an accounting of disclosures of protected health information.
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The right to obtain a paper copy of the Notice of Privacy Practices from this practice upon request.
This practice reserves the right to change the terms of this Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains.
I understand that I can obtain this practices current Notice of Privacy Practices upon request.