The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began April 14, 2003. Many of the policies have been incorporated into our practice for your safety. This form is a 'friendly' version, a more complete text is posted in the office. What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov We have adopted the following policies: 1. Patient information will be kept confidential except as necessary to provide services or manage administrative matters related to your care. This includes sharing information with healthcare providers, labs, and insurance as appropriate. Patient files may be stored in open racks but without identifiable coding. During normal care, records may be temporarily visible in areas like the front office or exam rooms, but only office staff will have access. 2. We may remind patients of their appointments via phone, email, mail, or other convenient methods. You may also receive updates on office policy or services. Receipts may include information for all family members, including future appointments and billing. 3. Vendors used by our practice may access PHI but must adhere to HIPAA confidentiality rules. 4. Government agencies or insurance payers may inspect the office and review documents including PHI as part of their duties. 5. You agree to bring any privacy concerns or complaints to the office manager or doctor. 6. Your confidential information will not be used for marketing or advertising purposes. 7. We agree to provide access to patient records in accordance with state and federal laws. 8. These policies may be changed, added to, or modified to better serve the needs of both the practice and patients. 9. You may have the right to request limitations on the use of your protected health information and changes to office policies. I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION AND CONSENT FORM and any subsequent changes in the offices policy. I understand that this consent shall remain in force from this time forward.
Main Street Dental 5205 Office Park Blvd. Bradenton, FL 34203 (941) 725-1128
All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
