EWING PATIENT INFORMATION

PATIENT INFORMATION
Name

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EMERGENCY CONTACT
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DENTAL INSURANCE
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Ewing Dental Associates Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Notice of Privacy Practices

Your Information - Your Rights - Our Responsibilities

THIS NOTICE DESCRIBES HOW MEDICAL/DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

YOUR RIGHTS

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment, or our operations.

We are not required to agree to your request, and we may say “no” if it would affect your care.

If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

We will include all the disclosures, except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free, but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting us using the information on the back page.

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

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Notice of Privacy Practices (cont.)

OUR USES AND DISCLOSURES

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat You

We can use your health information and share it with other professionals who are treating you. Ex: A doctor treating you for an injury asks another doctor about your overall health condition. Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Ex: We use health information about you to manage your treatment and services. Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Ex: We give information about you to your healthjhbf vv insurance plan so it will pay for your services.

How else can we use or share your health information? We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see www.hhs.gov/orr/privacy/hipaa/understanding/consumers/oindex.html.

Help with public health and safety issues

We can share health information about you for certain situations such as: Preventing disease

Helping with product recalls

Reporting adverse reactions to medications

Reporting suspected abuse, neglect, or domestic violence

Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ/tissue donation requests

We can share health information about you with organ procurement organizations. Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

For workers’ compensation claims

For law enforcement purposes or with a law enforcement official

With health oversight agencies for activities authorized by law

For government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Redisclosure:

Once your health information is properly disclosed outside our practice, it may be redisclosed by the recipient and may no longer be protected by federal privacy rules. We want you to understand this possibility.

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Notice of Privacy Practices (cont.)

Substance Use Disorder Records (Part 2):

If we receive records or information about your substance use treatment, those records may be subject to special federal protections under 42 CFR Part 2 and may be treated differently than other health information. We will describe how these records are used and disclosed, and any stricter protections that apply. If we do not maintain these records, we will state that in your Notice.

YOUR CHOICES

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in your care. Share information in a disaster relief situation.

Include your information in a hospital directory.

If you are not able to tell us your preference, for example if you are unconscious, we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission Marketing purposes.

Sale of your information.

Most sharing of psychotherapy notes.

In the case of fundraising:

We may contact you for fundraising efforts, but you can tell us not to contact you again.

OUR RESPONSIBILITIES

We are required by law to maintain the privacy and security of your protected health information.

We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

We must follow that duties and privacy practices described in this notice and give you a copy of it.

We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see:

https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html

CONTACT INFORMATION

If you have questions about this Notice, want to exercise any of your rights, or wish to file a complaint, contact:

Ewing Dental Associates

177 Scotch Road, Ewing Township, NJ 08534

P: (609)771-4111 | info@ewingdental.com

Pennington Dental Associates

31 North Main Street, Pennington, NJ 08534

P: (609)737-0288 | doctor@penningtondentalcenter.com

You may also file a complaint with the U.S. Department of Health and Human Services at the Office for Civil Rights.

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Signature of patient (Parent or Guardian if Minor)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Acknowledgement of Receipt of Notice of Privacy Policies

Privacy Is Important to Us
I received a copy of the Notice of Privacy Practices of Ewing Dental Associates. I hereby authorize, as indicated by my signature below, Ewing Dental Associates to use and to disclose my protected health information for any necessary clinical, financial, and insurance purpose, as authorized in the Patient Acknowledgement of Receipt of Notice of Privacy Policies form.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please check all your preferred means of communication

Other
Please list authorized persons with whom we may discuss your Protected Health Information (PHI). Please notify us if you desire to remove a name from this list in the future.
List each authorized person's name and your relationship to them. Please provide the best phone number to reach them in case of an emergency.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Assignment & Release
I nearby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorized the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by the dental office, I am obligated to pay said office in accordance with its credit terms and policy.

I certify that I have read or had read to me the content of this form and do realize the risks and limitations involved.
Signature - Patient/Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

PATIENT INFORMATION

EMERGENCY CONTACT

DENTAL INSURANCE

SECONDARY DENTAL INSURANCE?

EMPLOYMENT

DENTAL HISTORY

Select "yes" or "no" to indicate if you have or had any of the following:

MEDICAL HISTORY

DO YOU HAVE or HAVE YOU EVER HAD:

FEMALE

MALE

DO YOU HAVE AN ALLERGIC REACTION TO:

Please list any other medication(s), dosage, and frequency you are taking and for what reason.

PHARMACY

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Ewing Dental Associates Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Policies

Assignment & Release