Your health information may be used in the following ways in our office:

1. Treatment Procedures: Your health information within our office will be used to assist us in offering the best dental care available. This would include sharing your health information with physicians and laboratories (medical & dental) other dentists or health care personnel, dental assistants, business and administration office staff, dental hygienists or other personnel giving or aiding in your treatment.
2. Health Care Operations within our Office: This information could be used in the following ways: training and evaluation of our staff, students, intern dental assistants or clinical employees, insurance company audits, government agencies who wish to review our quality procedures and State and Federal certification of office and credential licensing.
3. Patient Abuse: By law, we are required to notify government agencies if we believe a patient has been abused in any way, domestically or neglectfully. This requires ethical judgment on our part.
4. Patient Helps and Reminders: Because dental care requires regular maintenance and care, appointment reminders or calls from our office will generally be used to aid in scheduling appointments. These could be sent to you by way of letter, postcard and mail, or by telephone. If you do not wish to have these sent to you, you need to inform us of such a decision.
5. Work with Third Parties or Directly with Patient: The use of your health information can be used in filing insurance forms by mail or electronically. Your insurance companies will and should be working with the same security as our office is.
6. Local or National Public Health and Safety: We might have to disclose your health information to Federal, military, local or national health authorities. This is very helpful in preventing outbreaks of contagious diseases, side effects of drugs used within the parameters of dentistry and developing new equipment for our profession.
7. People Whom You Give Permission to Share your Health Needs: These would include people in your family, people who are helping in your treatment such as relatives, friends and health care people. Sometimes and emergency prevents you from giving such permission in such a case we will use out judgment to make sure your information goes to people that are important in providing treatment and care for you.
8. Criminal Activity: By State and Federal law we can disclose your health information to officials of the law for victims of a crime or for information concerning a crime.
9. Final Authority: The above eight clarifications are the reasons for us to use your health information. If you desire us not to use it in the above ways or use it in other ways, we will require written permission from you as a patient.

You, as a patient, have rights to the use of your health information:

1. Your Right to Restrict: You can restrict any use of your health information. We have always tried to honor your wishes that are reasonable restrictions.
2. Communicating your Health Information to you confidentially: This communication can be done privately with no one but yourself present or by sealed envelope mailed to your residence or on the phone to you personally. We will honor any type of reasonable communication.
3. Your Rights to your Health Information: This includes: charting, x-ray and billing records. A reasonable finance charge for duplication of this information will be charged. This information would only be given to you personally and will not be sent by mail or given to a relative or friend.
4. Adding to and deleting your Health Information: This aids you in making sure your records are correct and complete. This request must be done in writing. Health information not preformed in our office will not be recorded on your record.
5. Documenting your Health Information: You have a right to know how and where we used your health information other than for health operations, payments and dental procedures. This will start by April 14, 2003 and is mandated by HIPPA. Please help us by not asking us to go back more than 6 years. A reasonable charge will be assessed for the copies and research time from our office at any time.
6. This Notice of Privacy Practices can be requested from our office at any time. We will gladly mail you a copy of your records. We have assigned a person in our office to be your representative. The purpose of this law is to protect you and your health information. If there are any future changes than what are listed above, we will gladly inform you and we will follow these guidelines in our office. If you have any complaints, please call our assigned representative at our office at any time or contact the Secretary of Health and Human Services.

We have always valued the privacy of our patient’s health information and will continue to do so in the future.

We would appreciate your acknowledgment of your receipt of our policy by signing below and returning this sheet to our office.

Thank you.