drshahcosmeticandfamilydentistry.com - Adults and Adult Children

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 but 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 Washington. This includes issues relating to your treatment, payment, and our health care 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 for 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 or released.

Collecting Protected Health Information (PHI)

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 data, medical history, health records, etc. While most of the information will be collected 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.

Any breach in the protection of your personal health information, including unauthorized acquisition, access, use, or disclosure, will be fully investigated, addressed, and mitigated as established by the HIPAA Privacy Rule. You have a right to and will be provided all information relating to any breach involving your personal PHI.

Your Rights as our Patient

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 U.S. Department of Health and Human Services.

Please ask if you have any questions about your privacy rights or the protection of your health information.

Cosmetic and Family Dentistry of Mill Creek * 16504 - 9th Avenue SE, Suite 103 Mill Creek, Washington 98012 - 425-742-3606

Acknowledgement of Receipt of Statement of Privacy Practices
I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Cosmetic and Family Dentistry of Mill Creek. 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.

Cosmetic and Family Dentistry of Mill Creek reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices 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.

ADDITIONAL DISCLOSURE AUTHORITY

In addition to the all allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below.
ANY MEMBER OF MY IMMEDIATE FAMILY

YESNO
SPOUSE ONLY

YESNO
OTHER (Please Specify):
Name of Patient or Personal Representative
Signature of Patient or Personal Representative

Clear
Date

MonthDayYear
Date
Description of Personal Representative's Authority

Welcome

We are pleased to welcome you to our practice. Please take a few minutes to out this form as completely as you can. If you have any questions we’ll be glad to help you. We look forward to working with you in maintaining your dental health.
PATIENT INFORMATION
Date

MonthDayYear
Date
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Soc. Sec #
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Sex

MaleFemale
Age
Birthdate

MonthDayYear
Date
Marital Status

SingleMarriedWidowedSeparatedDivorced
Patient Employed By
Occupation
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone
Please enter a valid phone number.
Spouse's Name
Spouse's Business Phone
Please enter a valid phone number.
Spouse Employed By
Occupation
Whom may we thank for referring you?
In case of an emergency, who should be notified?
Phone Number
Please enter a valid phone number.
Primary Insurance
Subscriber Name

First NameMiddle NameLast Name
Relation to Patient
Birthdate

MonthDayYear
Date
Soc. Sec#
Subscriber Employed By
Business Phone
Please enter a valid phone number.
Insurance Company Name
Group#
Phone#
Please enter a valid phone number.
Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of other dependents covered under this plan
Additional Insurance
Is patient covered by additional insurance?

YesNo
Subscriber Name

First NameMiddle NameLast Name
Relation to Patient
Birthdate

MonthDayYear
Date
Soc. Sec#
Subscriber Employed By
Business Phone
Please enter a valid phone number.
Insurance Company Name
Group#
Phone#
Please enter a valid phone number.
Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of other dependents covered under this plan

STATEMENT OF PRIVACY PRACTICES

Acknowledgement of Receipt of Statement of Privacy Practices

Welcome

PATIENT INFORMATION

Primary Insurance

Additional Insurance

Dental History

Medical History

Authorization