Statement of Privacy Practices
Our office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principal concept of our practice. We may, from time to time, amend our privacy policies and practices but we will always inform you of any changes that might affect your rights.
Protecting Your Personal Healthcare Information
We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Washington. This includes issues relating to your treatment, payment, and out health care operations. Your personal health information will never be otherwise given to anyone-even family members-without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose for any purpose.
Collecting Protected Health Information (PHI)
We will only request personal information needed to provide our standard of quality health care, implement payment activities, conduct normal health practice operations, and comply with the law. This may include your name, address, telephone number(s), email address, Social Security Number, employment data, medical history health records, etc. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.
Disclosure of your Protected Health Information
As stated above we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental officials under certain circumstances. We will not use your information for marketing purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointments including voicemail, answering machines, email, and postcards.
Your Rights as our Patient
Any breach in the protection of your personal health information, including unauthorized acquisition, access use, or disclosure, will be fully investigated, addressed and mitigated as established by the HIPPA Privacy Rule. You have a right to and will be provided all information relating to any breach involving your personal PHI.
You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services.
Please ask if you have any questions about your privacy rights or the protection of your health information.
Acknowledgement of Receipt of Statement of Privacy Practices
I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Cooley Smiles. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment of services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.
Cooley Smiles reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.
Cooley Smiles may at my request email records including but not limited to, financial, insurance and x-rays to myself or other dental providers.
Additional Disclosure Authority
In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare information to the persons indicated below.
Any Member of My Immediate Family: *
Spouse Only *
Other (Please Specify):
Patient's First Name: *
Patient's Last Name: *
The person filing out form is: *
-select- Patient Personal Representative
If Representative, Representative's Name: