STATEMENT OF PRIVACY PRACTICES
Our office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principal concept of our practice. We may, from time to time, amend our privacy policies and practices; though will always inform you of any changes that might affect your rights.

Protecting Your Personal Healthcare Information
We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the State of Texas. This includes issues relating to your treatment, payment, and our healthcare operations. Your personal health information will never be otherwise given to anyone – even family members – without your written consent. You, of course, may give written authorization fro us to disclose your information to anyone you choose, for any purpose.

Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current and future patients, so you can be confident that your protected health information will never be improperly disclosed and released.

Collecting Protected Health Information
We will only request personal information needed to provide our standard of quality health care, implement payment activities, conduct normal health practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment date, medical and/or dental history, health records, etc. While most of the information will be from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.

Disclosure of your Protected Health Information
As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental officials under certain circumstances. We will not use your information for marketing purposes without your written consent.

We may use and/or disclose your health information to communicate reminders about your appointments including voicemail messages, answering machines, and postcards.

Patient Rights
You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the US Department of Health and Human Services.

We thank you for being a patient at our office. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.

Thad H. Gillespie D.D.S., Chris Felicetta D.D.S.

 

I acknowledge that I received a copy of the Statement of Privacy Practices for the office of Thad H. Gillespie, DDS and Chris Felicetta, DDS. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Thad H. Gillespie, DDS and Chris Felicetta, DDS reserve the right to change the privacy practices that are described in the Statement of Privacy Practices. If the privacy practices change, I will be offered a copy of the revised Statement of Privacy Practice at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.

By signing this form, you also give permission for our office to share your treatment information with approved dental providers and/or your insurance company either by electronic, written or verbal disclosure.

Pursuant to the Texas Administrative Code, Title 22, Part 9, Chapter 165, Rule §165.2: In the case you need to request your records from our office, Liberty Hill Dental, P.A is required to provide those to you within 15 business days of the requested date. Please submit your request in writing to our office at the above address. Applicable charges may be assessed.