Hippa – Privacy Policy Form

We value privacy of our patients and take appropriate measures to protect it.

This notice describes how medical/dental information about you may be used and disclosed and how you can
get access to this information. Please review it carefully

This notice of Privacy Practice describes how we may use and disclose your protected health information (PHI) to carry treatment, payment or health care operation and for the other purpose that are permitted or required by law. It also describes your right to access and control your protected health information. “Protected health information” is information about you that includes demographic information which may identify you and relates to your past, present or future physical or mental health or condition and related health care services.

1. Uses and Disclosures of protected Health Information

Uses and disclosures of protected health information.

Your protected health information may be used and disclosed by your dentist, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to
you, to pay your health care bills, to support the operation of the dentist’s practice, and any other use required by law.


We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For the example, your protected health information may be provided to a dentist to whom you have been referred to ensure that the dentist has the necessary information to diagnose or treat you.


Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations:

We may use or disclose, as-needed, your protected health information in order to support the business activities, training of dental students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to dental school students that see patients in our office. In addition, we may use sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information as necessary, to contact you to remind you of you appointment.

We may use or disclose you protect health information in the following situations without your authorization. These situations include: as required by law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceeding: Law Enforcement: Coroners, Funeral Directors, and Organ Donation Research: Criminal Activity: Military Activity and National Security: Workers’ Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures Will Be Made Only with your Consent, Authorization or Opportunity to object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician’s practice has taken an action reliance on the use disclosure indicated in the authorization.

Your Rights

Following is a statement of your rights with respect to your protected health information

You have the right to request a restriction of your protected health information. This meant you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practice. Your Request must state the specific restriction requested and to whom you want the restriction to apply.

Your dentist is not required to agree to a restriction that you may request. If dentist believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Health Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You may have the right to have you dentist amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.


You may complain to us or the Security of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filling a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please as to speak with HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Signature below is only acknowledgement that you have received this Notice or our Privacy Practices:

Following is an addendum in compliance with the Hippa Law (September 23, 2013)

Financial Conflicts:

Any personal information will not be sold or used for marketing or advertisement out of this office.

Any patient that chooses to pay in cash for a procedure and asks that it not be disclosed to an insurance company, it will not be disclosed.

In the event of a breach you will be notified immediately.

All patients have the right to a copy of their chart and x-rays.

If you like to discuss this further or have any question about how we implement this policy please feel free to call at 770-478-6878 or ask questions to our front desk personnel.


Authorization for release of Protected Health Information to other persons and entities-

I authorize the release of any and all of my health information including dental records, and digital x-rays, models ,photographs, videos, diagnoses and treatment rendered or treatment planned, and also the release of the financial and/or insurance claims related matters and information. I release my Protected Health Information as deemed necessary for Treatment, reimbursement and other Healthcare Operations by electronic transmission, including fax and e-mail, couriers and by U.S. Mail.

This information can be released to


Working Hours

Mon-Wed: 9 AM to 6 PM

Thurs: 12 PM to 8 PM

Fri : 10 AM to 3 PM

Sat : 10 AM to 6 PM