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Signature I agree that the information provided in this form is correct to the best of my knowledge. Streeter Dental 1/1 (719) 590 6266 1685 Briargate Blvd. Suite A Colorado Springs, Colorado 809203464 [email protected] Date Privacy Policy (HIPAA) This office is dedicated to protecting the privacy of our patients and their information. Each employee commits to ensure that your information is never compromised. We may amend our privacy policies, but will always inform you of any changes that might affect your rights. We use and disclose your information as dictated by the Health Insurance Portability and Accountability Act and the State of Colorado. This includes issues relating to your treatment, payment, and health care operations. Your personal health information will never be otherwise given to anyone without your written consent. You may give written authorization to disclose your information to anyone for your purposes. Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients. We will request personal information needed to provide treatment, implement payment activities, conduct normal dental practice operations, and comply with the law. This includes your name, address, telephone number, Social Security Number, employment data, medical history, health records, etc. We will not use your information for marketing purposes. We may be required by law to disclose certain information to law enforcement and government officials under certain circumstances. You have a right to request copies or your healthcare information and to request a list of instances in which we, or our business associates, have disclosed your protected information for the uses listed 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, notify us immediately. Acknowledgement of Office Privacy Practices

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Page 1: Privacy Policy Printable... · treatment, implement payment activities, conduct normal dental practice operations, and comply with the law. This includes your name, address, telephone

Signature

I agree that the information provided in this form is correct to the best of my knowledge.

Streeter Dental 1/1

(7 19) 590 62661685 Briargate Blvd. Suite A Colorado Springs, Colorado 809203464 [email protected]

Date

Privacy Policy (HIPAA)

This office is dedicated to protecting the privacy of our patients and their information. Each employee commits to ensure that your information is never compromised. We may amend our privacy policies, but will always inform you of any changes that might affect your rights. We use and disclose your information as dictated by the Health Insurance Portability and Accountability Act and the State of Colorado. This includes issues relating to your treatment, payment, and health care operations. Your personal health information will never be otherwise given to anyone without your written consent. You may give written authorization to disclose your information to anyone for your purposes. Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients. We will request personal information needed to provide treatment, implement payment activities, conduct normal dental practice operations, and comply with the law. This includes your name, address, telephone number, Social Security Number, employment data, medical history, health records, etc. We will not use your information for marketing purposes. We may be required by law to disclose certain information to law enforcement and government officials under certain circumstances.

You have a right to request copies or your healthcare information and to request a list of instances in which we, or our business associates, have disclosed your protected information for the uses listed 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, notify us immediately.

Acknowledgement of Office Privacy Practices