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Discovery Dental Shelby

100 W Main St,
Shelby, OH, 44875
(419) 342-4217

Patient Details( * mandatory to fill )
Spouse/Parent/Guardian( * mandatory to fill )
Insurance Information( * mandatory to fill )
Health History( * mandatory to fill )

Have you ever had any of the following? Please check

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Health History( * mandatory to fill )
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Health History( * mandatory to fill )
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Please Check If all these apply

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Do you have any of the following?

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To the best of my knowledge; ALL the preceding answers and information provided are true and correct. If I ever have any change in my health, or if my medicines change, I will inform the doctors at the next appointment without fail.

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Primary Insurance Details( * mandatory to fill )
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HIPPA Form( * mandatory to fill )

Protecting Your Confidential Health Information is Important to Us

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.

Our Promise

Dear Patient:

This notice is not meant to alarm you. Quite the opposite! It is our way to communicate to you that we are taking the Federal law (HIPAA-Health Insurance Portability and Accountability Act) very seriously. This is to protect the confidentiality of your health information. We never want you to delay treatment because you are afraid your personal health history might be unnecessarily made available to others outside our office.

Why do you have a privacy policy?

The Federal government legally enforces the importance of the privacy of health information largely in response to the rapid evolution of computer technology and its use in healthcare. The government has appropriately sought to standardize and protect the privacy of the electronic exchange of your health information. We reserve the right to change our privacy practices and the terms of the Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request.

As Required By Law

We may use or disclose your health information as required by any statue, regulation, court order or other mandate enforceable in a court of law.

Abuse or Neglect

We may disclose your health information to the responsible government agency if (a) the Privacy Official reasonably believes that you are a victim of abuse, neglect, or domestic violence, and (b) we are required or permitted by law to make the disclosure. We will promptly inform you that such a disclosure has been made unless the Privacy Official determines that informing you would not be in your best interest to you.

Public Health and National Security

We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. Health information could be important when the government believes that public safety could benefit under prevention of an epidemic or a new side effect of a drug treatment.

Law Enforcement

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

HIPPA Form( * mandatory to fill )

How we may use and disclose health information about you.

We will use and communicate your HEALTH INFORMATION only for the purposes of providing your treatment, obtaining payment, conducting healthcare operations, and as otherwise described in this notice. We will use your HEALTH INFORMATION within our office to provide you with care. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care. In addition, we may share your health information with pharmacies or other healthcare personnel providing you treatment.

Payment

We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claim management, and determinations of eligibility, and coverage to obtain payment from you, an insurance company, or another third party.

Healthcare Operations

We may disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conduction training programs, and licensing activities. Also included can be disclosed during audits by Insurance companies or government appointed agencies as part of their quality assurance and compliance reviews.

Patient Reminders

Because we believe regular care is very important to your health, we will remind you of your upcoming appointments or appointments needed in the future. We may contact you either via phone, postcards, letters, email or by text message. (Unless you tell us you do not want to receive these reminders).

Business Associates

We have contracted with one or more third parties (referred to as a business associate) to use and disclose your health information to perform services for us.

Family, Friends, and Caregivers

We may share your health information with those you tell us will be helping you with our treatment, medications, or payment. We will ask permission first. In case of an emergency, where you are unable to tell us what you want, we will use our judgment when sharing it.

Workers Compensation

We may disclose your health information as required or permitted by compensation laws.

Workers Compensation

We may disclose your health information as required or permitted by compensation laws.

Incidental Use & Disclosures

We may use or disclose you r health information in a manner which is incidental to the uses and disclosures describe in this notice.

Health Activities

We may disclose health info to government agency overseeing the health care system.

Coroners, Medical Examiner, and Funeral Directors

We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.

Fundraising

We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications.

Other Uses and Disclosures of PHI

Your authorization is required, with a few exceptions, for disclosure psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this Notice (or as otherwise permitted or required by law). You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.

You’re Health Information Rights Access

You have the right to look at or get copies of your health information, with limited exceptions. You must make the request in writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible. If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.

HIPPA Form( * mandatory to fill )

Disclosure Accounting

With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to the additional requests.

Alternative Communication

You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contract you using the ways or locations you have requested we may contact you using the information we have.

Amendment

You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. IF we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.

Right to Notification of a Breach

You will receive notifications of breaches of your unsecured protected health information as required by law.

Electronic Notice

You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically on our Website or by electronic mail (e-mail).

Questions or Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or if you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your Health Information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Patient Acknowledgment

Thank you very much for taking time to review how we are carefully using your health information. If you have any questions we want to hear from you. If not, we would appreciate very much your acknowledging your receipt of our policy by signing this form.

 

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