Dental Registration And History Form (Page 6 of 7) in pdf

Atwood Family Dental

2455 E. 11

Street

Odessa, Texas

_________________________________________________

NOTICE OF PRIVACY PRACTICES

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.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give

you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the

privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in

effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by

applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all

health information that we maintain, including health information we created or received before we made the changes. Before we

make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this

Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare

operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare

professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing,

or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give

us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you

may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it

was in effect. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those

described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this

Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your

healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying

or locating) a family member, your personal representative or another person responsible for your care, of your location, your general

condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an

opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health

information based on a determination using our professional judgment disclosing only health information that is directly relevant to

the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to

make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other

similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written

authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Dental Registration And History Form Page 6

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