HIPAA

HIPPA covers the authorization for release of Protected Health Information to family members, significant others, and/or friends. It also discusses the portability and accessibility of your health record so that other medical professionals may easily access your records to provide continuity of care.

This authorization for release of information will remain in effect until terminated in writing. 

I authorize the release of any and all health information including diagnosis, dental records, digital x-rays rendered and the release of financial and/or insurance claims information.

 

This information may be released to:

I do not authorize anyone but myself to discuss my personal health information. Information may only be released to me.

Authorization for release of Protected Health Information to Dental/Medical Professionals for treatment, payment and healthcare operations: I authorize the release of my Protected Health Information as necessary for treatment, payment and healthcare operations by electronic transmission, including e-mail, facsimile and by U.S. Mail.

It is the policy of Asheville Smiles to protect the electronic transmission of PHI as well as to fulfill our duty to protect the confidentiality and integrity of our patient's PHI as required by law, professional ethics, and accreditation requirements. The information released will be limited to the minimum necessary to meet the requestor's needs. Acknowledgement of receipt of Notice of Privacy Practices I have read and/or been given a copy of Asheville Smiles Notice of Privacy Practices, which describes how my health information is used and shared.

I understand that should I request my records be sent to another dental or medical professional, I must complete a release of medical records. Asheville Smiles Cosmetic and Family Dentistry has 30 days to complete the request. A fee may be applied to duplicate medical records.

I understand that Asheville Smiles has the right to change this notice at any time. I understand that I may obtain a current copy by asking Asheville Smiles Cosmetic & Family Dentistry.

My signature below acknowledges that I have read and/or been provided with a copy of the Notice of Privacy Practices.