understand that as a part of my healthcare, this facility originates and maintains health records describing my child’s health history, symptoms, examinations and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as:

• A basis for planning my care and treatment;

• A means of communication among the health professionals who may contribute to my healthcare;

• A source of information for applying my child’s diagnosis and surgical information to my bill;

• A means by which a third-party payer can verify that services were actually provided;

• A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals
 

understand that as a part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this facility’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.

• Ask us to restrict our use and disclosure for purposes of treatment or payment. This facility is not required by law to agree to the restrictions requested.

• Ask us to communicate with you in a confidential way, such as phoning you at work or by email.

• To receive photocopies of your health information, we ask for a 24 hour notice. There will be a $10 charge for all information.

• Ask us to amend your health information if you think that it is incorrect or incomplete.

• Get a list of the disclosures that we have made of your health information within the past six years. Please allow 30 days to receive the information.

• Get additional paper copies of this Notice of Privacy Practice please ask the front desk.

We reserve the right to change this notice at any time as allowed by law. If we change any of the information you may be asked to complete a new form. You may also request a copy of any changes made to our notice of privacy practices.

If we need to disclose your health information outside of our office for any reason we will ask for your written permission.
 

The law allows or requires us to use or disclose your health information without your permission,

• When a state or federal law mandates that certain health information be reported for a specific purpose.

• Such as contagious disease reporting, investigation or surveillance and notice to and from the federal Food and Drug Administration regarding drugs or medical devices.

• To inform governmental authorities about victims of suspected abuse, neglect or domestic violence, or a crime that happens somewhere else.

• For licensing of doctors for audits by Medical and Medicare, for investigation of possible violations of health care laws.

• For judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies.

• To a medical examiner to identify a death of person or to determine the cause of death, or to a funeral directors to aid in burial, or to organizations that handle organ or tissue donations.

• Worker’s compensation programs.

We may have Revenue Well contact you by text message or email. We may call and leave reminders to a cell phone, email, place of work or at home, unless we are notified otherwise in writing to kept in the patient chart.

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for civil Rights.
 

I acknowledge that I have read and signed a copy of Kids Stop Dental Notice of Privacy Practices.