Patient Notice of Privacy Practices Form

  • Notice of Privacy Practices - (HIPPA)

    How Your Health Information May Be Used
  • To Provide Treatment

    We will use your health information within our office to provide you with the best dental care possible. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between hygienist, dental assistant, dentist and business office staff. In addition, we may share your health information with physicians, referring, dentists, clinical and dental laboratories, pharmacies or other health care personnel providing you treatment.

    To Obtain Payment

    We may include your health information with an invoice used to collect payment for treatment you receive in our office. We may do this with insurance forms filed for you in the mail or sent electronically.

    To Conduct Health Care Operations

    Your health information may be used during performance evaluations of our staff. Some of our best teaching opportunities use clinical situations experienced by patients receiving care at our office. As a result, health information may be included in training programs for students, interns, associates, and business and clinical employees. It is also possible that health information will be disclosed during audits by insurance companies or government appointed agencies as a part of their quality assurance and compliance reviews. Your health information may be reviewed during the routine process of certification, licensing or credentialing activities.

    In Patient Reminders

    Because we believe regular care is very important to your oral and general health, we will remind you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow up on your care and inform you of treatment options or services that may be of interest to you and your family. These communications are an important part of our philosophy of partnering with our patients to be sure they receive the best preventative and restorative care modern dentistry can provide. They may include postcards, letters, telephone reminders, or email (unless you notify us in writing that our do not wish to receive these reminders.)

    Abuse or Neglect

    We will notify government authorities if we believe a patient is the victim of abuse, neglect or domestic violence. We will make this disclosure only when we are compelled by our ethical judgment, when we believe we are specifically required or authorized by law or with the patient’s agreement.

    Public Health and National Security

    We may be required to disclose to Federal officials or military authorities health information necessary to complete an investigation related to public health or national security. Health information could be important when the government believes that the public safety could benefit when the information could lead to the control or prevention of an epidemic or the understanding of new side effects of a drug treatment or medical device.

    For Law Enforcement

    As permitted or required by State or Federal law, we may disclose your health information to a law enforcement official for certain law enforcement purposes including under certain circumstances, if you are a victim of a crime or in order to report a crime.

    Family, Friends, and Caregivers

    We may share your health information with those you notify us in writing will be helping you with your home hygiene, treatment, medications or payment.

    Authorization to Use or Disclose Health Information

    Other than is stated above or where Federal, State or Local law requires us, we will not disclose your health information other than with your written authorization. You may revoke that authorization at any time in writing.
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