• SUMMARY OF PRIVACY PRACTICES FOR SOUTHWOODS PEDIATRIC DENTISTRY

  • This is a summary of our condensed version of our Notice of Privacy Practices. Our full-length Notice is available upon request. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU AND YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY. We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your protected health information is kept private. How will we use or disclose your information? Here are a few examples:

    • For medical treatment
    • The right to obtain Covid-19 testing results
    • Use of a remote company to complete office tasks. The company does have offshore employees
    • Obtain payment for our services
    • In emergency situations
    • The right to call your home or other designated locations and leave a message on voicemail or in person in reference to any items that will assist the practice in carrying out treatment, payment, and healthcare operations (TPO); such as for appointment and patient recall reminders, insurance items and any call pertaining to my child’s clinical care, including laboratory results among others.
    • The right to Mail or Email to your home or other designated location items that assist the practice in carrying out (TPO), such as appointment reminder cards and patient statements
    • To run our Practice more efficiently and ensure all our patients receive quality care
    • To avert a serious threat to health or safety
    • In response to certain requests arising out of lawsuits or other disputes

    If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our patient care coordinator. All complaints must be submitted in writing. You will not be penalized for filing a complaint. You have certain rights regarding the information we maintain about you. However, the practice does not have to agree to my requested restrictions. These rights include:

    • The right to inspect and copy
    • The right to request restrictions
    • The right to amend or revise its Notice of Privacy at any time
    • The right to an accounting of disclosures
    • The right to a paper copy of this notice
    • The right to request confidential communications

    For more information about these rights, please see the detailed Notice of Privacy Practices that follows this summary. By signing this, I am allowing Southwoods Pediatric Dentistry to use and disclose my protected health information for TPO. I am also giving permission to all of the items listed above on this summary sheet. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.

  • I hereby acknowledge receipt of Southwoods Pediatric Dentistry and provide consent for release of information.

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