MY ASHBURN DENTIST
HIPAA
This notice describes how medical information about you may be used and disclosed and how you can get access to this information
HIPAA Notice of Privacy Practices
Please Review Carefully
Who Will Follow This Notice:
This notice describes our company’s practices and that of:
- The dental practice at which you receive treatment.
- Any health care professional authorized to enter information into your medical chart located with the practice as to the information they enter into our records.
- All employees and staff
Our Pledge Regarding Medical Information:
We understand that medical information about you and your health is personal. We are committed to protecting the confidentiality of your medical information. We create a record of the care and services you receive at this practice. We need this record to provide you with quality care and to comply with various legal requirements. This notice applies to any hospital or other health care personnel records of your care or created by the dental professional.
How We Will Be Use or Disclose Your Health Information:
The dental practice will only use and disclose your private health information in accordance with applicable state or federal law. The Health Insurance Portability and Accountability act, “HIPAA”, creates additional rights and responsibilities for patients and health care providers.
Changes to our Privacy Practices:
We reserve the right to make changes to our privacy practices as described in this notice. This includes our practices as to information about you that we have already received as well as information we received after the date of the change.
For More Information or to Report a Problem:
If you believe that your privacy rights have been violated, you may file a complaint with the Secretary of the Federal Department of Health and Human Services. There will be no retaliation for filing a complaint.
Today’s Date: [datetoday]
I consent to the above:
