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to the orthodontist

HIPAA CONSENT FORM

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. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

Your protected health information (i.e. individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographics) may be used or disclosed by us, electronically or physically, in one or more of the following respects:

• To other healthcare providers (i.e.general dentist, oral surgeon,etc.) in connection with our rendering orthodontic treatment to you;
• To third party payors or spouses (i.e.insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account;
• To certifying, licensing and accrediting bodies (i.e.the American Board of Orthodontics, state dental boards,etc.) in connection with obtaining certification, licensure or accreditation;
• Internally, to all staff members who have any role in your treatment;
• To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.;
• To other patients or prospective patients, in print or electronic form, for marketing purposes, limited to photos, first names, ages and basic treatment information;
• To your family and close friends involved in your treatment;
• We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you;
• Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke;

Under the new privacy rules, you have the right to

• Request restrictions in the use and disclosure of your protected health information (PHI);
• Request confidential communication of your PHI;
• Inspect and obtain copies of your PHI through asking us;
• Amend or modify your PHI in certain circumstances;
• Receive an accounting of certain disclosures made by us of your PHI;
• You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation).
• We have the following duties under the privacy rules:
• By law, to maintain the privacy of protected health information (PHI) and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
• To abide by the terms of our Privacy Notice that is currently in effect; and to advise you of your right to change the terms of the Privacy Notice and to make the new notice provision effective for all PHI maintained by us, and if we do so, we will make available to you a copy of the revised Privacy Notice.
• Please note that we are not obligated to:
• Honor any request by you to restrict the use or disclosure of your PHI;
• Amend your PHI if, for example, it is accurate and complete;
• Provide an atmosphere that is totally free of the possibility that your PHI may be incidentally overheard by other patients or third parties.
• This Privacy Notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask our Privacy Contact Person. Thank you.
• Patient Acknowledgement
• I hereby acknowledge that I have received and reviewed a copy of this Privacy Notice.