New Patient Information Form
Personal Information
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
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Your protected health information is accessed and
used for healthcare related purposes only.
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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.
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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.
Certain Circumstances
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.
Patient Rights
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You have the right to request in writing to inspect
and/or receive a copy of yourhealth information. *
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You have the right to request an alternate means or
location to receive communications regarding your
health information. *
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You have the right to request in writing to amend,
correct, or delete any recorded health information
within our possession. *
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You have the right to request in writing to restrict
some of the uses and disclosures of your health
information. *
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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.