Notice Of Privacy Practice

Downtown Dental Design

Notice of Privacy Practice

Dear Patient:

Our ofﬁce is committed in protecting the conﬁdentiality of your health information.

The “ Privacy Act” enforced by the federal government protects health information

that is maintained by physicians, hospitals and other health care providers and

health plans.

The notice of privacy Act will explain our privacy practices, and it contains very

important information about how your conﬁdential health/dental information is

handled in our ofﬁce. It also describes how you can exercise your right with regard

to your protected health/dental information.

By signing this consent form, you are giving us the consent to use and disclose

your health information in a protected and conﬁdential manner to carry out

treatment, payment activities and health care operations.

Signature:___________________________Date: _____________________

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Parent category: Legal