Oceanspray Dental Health

5122 Olympic Dr, Suite B-204, Gig Harbor, WA 98335

My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA). I understand that this information can and will be used to:

• Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly.

• Obtain payment from third-party payers for my health care services

• Conduct normal health care operations such as quality assessments and improvement activities

I have been informed of my dental provider’s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations and I understand that you are not required to agree to my requested restriction, but if you do agree then you are bound to abide by such restrictions.

PATIENT NAME:

DATE:

SIGNATURE:

RELATIONSHIP TO PATIENT:

DEPENDENT FAMILY MEMBERS ALSO COVERED BY THIS ACKNOWLEDGMENT:

Additional Disclosures Authority

OTHER?

Your Signature

OTHER?

Their Name/Your Signature

OTHER-SPECIFY

Their Name/Your Signature

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The health Insurance Portability & Accountability Act of 1996 (HIPPA) requires all health care records and other individually identifiable health information used or disclosed to us in any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPPA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

Office Use Only

We were unable to obtain the patient’s written acknowledgment of our Notice of Privacy Practices due to the following reason:

The Patient refused to sign

Communication barriers

Emergency situation

Other

Without specific written authorization, we are permitted to use and disclose your health care records for the purposes of treatment, payment and health care operations.

• Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. For example, we may need to share information with other providers or specialists involved in the continuation of your care.

• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. For example, we disclose treatment information when billing a dental plan for your dental services.

• Health Care Operations include the business aspects of running our practice. For example, patient information may be used for training purposes, or quality assessment.

Unless you request otherwise, we may use or disclose health information to a family member, friend, or other personal representative to the extent necessary to help with your healthcare or with payment for your healthcare. In addition, we may use your confidential information to remind you of appointments by sending reminder postcards and/or leaving messages at home and/or work. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have certain rights in regards to your protected health information, which you can exercise by presenting a written request to our Privacy Officer at the practice address listed below:

• The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

• The right to request to receive confidential communications of protected health information from us by alternative means or at alternative locations.

• The rights to access inspect and copy your protected health information.

• The right to request an amendment to your protected health information

• The right to receive an accounting of disclosures of protected health information outside of treatment, payment and health care operations.

• The right to obtain a paper copy of this notice from us upon request.

• We are required by law to maintain the privacy of your protected health information and to provide you with notice of your legal duties and privacy practices with respect to protected health information.

This notice is effective as of April 14, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. Revisions to our Notice of Privacy Practices will be posted on the effective date and you may request a written copy of the Revised Notice from this office.

You have the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, in the event you feel your privacy rights have been violated. We will not retaliate against you for filing a complaint.

For more information about our Privacy Practices, please contact: Remy Rogers, DDS 5122 Olympic Dr, Suite B-204, Gig Harbor, WA 98335 P: 253-853-3315 F: 253-853-7093

For more information about HIPPA or to file a complaint: The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Avenue, S.W. Washington, D.C. 20201 P: 877-696-6775 (toll-free)