NOTE: Both doctor and patient are encouraged to discuss any and
all relevant patient health issues prior to treatment.
Acknowledgement of Receipt of Notice of Privacy Practices
Purpose: This form is used to obtain acknowledgement of receipt of
our Notice of Privacy Practices or to document our good faith
effort to obtain that acknowledgement.
Authorization to Release Information
Purpose: This form is used to obtain authorization regarding
patient covered under the Privacy Act to people other than
For office use only
We attempted to obtain written acknowledgement of our receipt of
out Notice of Privacy Practices, but acknowledgment could not be
obtained because individual refused to sign
For completion by dentist
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
We are required by law to maintain the privacy of protected health
information, to provide individuals with notice of our leg al
duties and privacy practices with respect to protected health
information, and to notify affected individuals following a breach
of unsecured protected health information. We must follow the
privacy practices that are described in this Notice while it is in
effect. This Notice takes effect 9/23/2013 and will remain in
effect until we replace it.
We reserve the right to change our privacy practices and the terms
of this Notice at any time, provided such changes are permitted by
applicable law, and to make new Notice provisions effective for
all protected health information that we maintain. When we make a
significant change in our privacy practices, we will change this
Notice and post the new Notice clearly and prominently at our
practice location, and we will provide copies of the new Notice
You may request a copy of our Notice at any time. For more
information about our privacy practices, or for additional copies
of this Notice, please contact us using the information listed at
the end of this Notice.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
We may use and disclose your health information for different
purposes, including treatment, payment, and health care
operations. For each of these categories, we have provided a
description and an example. Some information, such as HIV-related
information, genetic information, alcohol and/or substance abuse
records, and mental health records may be entitled to special
confidentiality protections under applicable state or federal law.
We will abide by these special protections as they pertain to
applicable cases involving these types of records.
Treatment. We may use and disclose your health information
for your treatment. For example, we may disclose your health
information to a specialist providing treatment to you.
Payment. We may use and disclose your health information
to obtain reimbursement for the treatment and services you receive
from us or another entity involved with your care. Payment
activities include billing, collections, claims management, and
determinations of eligibility and coverage to obtain payment from
you, an insurance company, or another third party. For example, we
may send claims to your dental health plan containing certain
Healthcare Operations. We may use and disclose your health
information in connection with our healthcare operations. For
example, healthcare operations include quality assessment and
improvement activities, conducting training programs, and
Individuals Involved in Your Care or Payment for Your Care.
We may disclose your health information to your family or friends,
or any other individual identified by you when they are involved
in your care or in the payment for your care. Additionally, we may
disclose information about you to a patient representative. If a
person has the authority by law to make health care decisions for
you, we will treat that patient representative the same way we
would treat you with respect to your health information.
Disaster Relief. We may use or disclose your health
information to assist in disaster relief efforts.
Required by Law.We may use or disclose your health
information when we are required to do so by law.
Public Health Activities.We may disclose your health
information for public health activities, including disclosures
- Prevent or control disease, injury or disability
- Report child abuse or neglect
Report reactions to medications or problems with products or
Notify a person of a recall, repair, or replacement of products
Notify a person who may have been exposed to a disease or
Notify the appropriate government authority if we believe a
patient has been the victim of abuse, neglect, or domestic
National Security. We may disclose to military authorities
the health information of Armed Forces personnel under certain
circumstances. We may disclose to authorized federal officials
health information required for lawful intelligence,
counterintelligence, and other national ecurity activities. We may
disclose to correctional institution or law enforcement official
having lawful custody the protected health information of an
inmate or patient.
Secretary of HHS. We will disclose your health information
to the Secretary of the U.S. Department of Health and Human
Services when required to investigate or determine compliance with
Worker's Compensation. We may disclose your PHI to the
extent authorized by and to the extent necessary to comply with
laws relating to worker's compensation or other similar programs
established by law
Law Enforcement. We may disclose your PHI for law
enforcement purposes as permitted by HIPAA, as required by law, or
in response to a subpoena or court order.
Health Oversight Activities. We may disclose your PHI to
an oversight agency for activities authorized by law. These
oversight activities include audits, investigations, inspections,
and credentialing, as necessary for licensure and for the
government to monitor the health care system, government programs,
and compliance with civil rights laws.
Judicial and Administrative Proceedings. If you are
involved in a lawsuit or a dispute, we may disclose your PHI in
response to a court or administrative order. We may also disclose
health information about you in response to a subpoena, discovery
request, or other lawful process instituted by someone else
involved in the dispute, but only if efforts have been made,
either by the requesting party or us, to tell you about the
request or to obtain an order protecting the information