New Patient Information Form
Secondary Dental Insurance
Notice of Privacy Practices
All information that is obtained from you by this office is protected and kept confidential. Every reasonable measure to prevent unauthorized disclosure of your protected health information is practiced.
Uses and Disclosures
- Your protected health information is accessed and used for healthcare related purposes only.
- Your protected health information is never sold, rented, transferred, exchanged, and/or used for non-healthcare related purposes including marketing activities without your written authorization.
- Your protected health information is disclosed to third-party entities without your written authorization for the purpose of treatment, to obtain payment for treatment, and for healthcare operations.
Your protected health information can be disclosed without your written authorization in certain limited circumstances,
- Medical emergencies
- In situations required by law
- Individuals involved in your care
- When requested by public health agency
- When requested by a law enforcement agency
For any purpose other than treatment, obtaining payment, healthcare operations, or certain circumstances, we will ask for your written authorization before using or disclosing your protected health information. If you choose to sign an authorization to disclose protected health information, you can revoke that authorization in writing at any time.
- You have the right to request in writing to inspect and/or receive a copy of yourhealth information. *
- You have the right to request an alternate means or location to receive communications regarding your health information. *
- You have the right to request in writing to amend, correct, or delete any recorded health information within our possession. *
- You have the right to request in writing to restrict some of the uses and disclosures of your health information. *
- You have the right to request in writing an accounting of certain disclosures of your health information that were made by this office. *
* Conditions and limitations may apply; obtain additional information from front desk.