I have been provided a copy of the HIPAA Statement for Jeffrey Kwong Orthodontics, I have reviewed and signed it and have no outstanding questions. I provide consent for Jeffrey Kwong Orthodontics to leave a message on all the numbers provided on the intake forms. I understand that texts, emails and phone messages may not meet the HIPPA compliance standards if I elect for their use. I provide permission for Jeffrey Kwong Orthodontics to contact me in the following ways:
⦁ Traditional Mail
If you want more information about our privacy prctices, or have questions or concerns, please contact Jeffrey Kwong DDS MSD at:
Telephone: (916) 933-0532
Fax: (916) 933-0678
Address: 4693 Golden Foothill Pkwy
El Dorado Hills, CA 95762
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we 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 alternative locations, you may send a written complaint to our office or to the U.S. Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint.