Hipaa Form Dental Office PDF Details

The Health Insurance Portability and Accountability Act (HIPAA) Dental Office form plays a critical role in safeguarding patient privacy by outlining how personal health information can be used and disclosed within dental practices. Effective on September 23, 2013, and revised to reflect the 2013 HIPAA/HITECH Omnibus Final Rule, this form is pivotal in informing patients about their rights and the commitment of dental offices to protect their confidential health information, also known as protected health information (PHI). Elements Dental, like many other healthcare providers, is obligated by federal and state laws to maintain the privacy of individually identifiable health information, and this notice serves to communicate their practices and the measures in place to protect patient data. It covers a range of uses and disclosures from treatment, payment, and healthcare operations to more specific instances where information might be shared, such as with business associates, for research purposes, or in situations involving legal proceedings and law enforcement. Importantly, the document emphasizes the rights of patients to access, inspect, and amend their health information, request an accounting of disclosures, and receive notification of breaches of unsecured PHI. The notice also addresses situations requiring patient authorization for uses and disclosures not specifically covered by the notice or by law, reflecting a comprehensive approach to patient privacy and rights. This form is a cornerstone of patient privacy advocacy within dental practices, ensuring that patients are well-informed and that their information is handled with the utmost care and respect.

Form NameHipaa Form Dental Office
Form Length9 pages
Fillable fields0
Avg. time to fill out2 min 15 sec
Other namesprintable dental hipaa forms, dental hipaa form 2019, hipaa privacy notice 2019 printable, hipaa consent form dental office

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HIPAA Notice of Privacy Practices

Revised to reflect the 2013 HIPAA/HITECH Omnibus Final Rule

This Notice describes how health information about you may be used and disclosed and how you can get access to this information. This Notice provides you with information to protect the privacy of your confidential health care information, hereafter referred to as protected health information (PHI). The Notice also describes the privacy rights you have and how you can exercise those rights. Please review it carefully.

If you have any questions about this Notice, please Kindra O’Rielley at 740-966-0011 or Kindra@ElementsDentalOfJohnstown.com.

This Notice is effective on September 23, 2013.


Elements Dental is committed to maintaining and protecting the confidentiality of our employees’ personal information. This Notice of Privacy Practices applies to Elements Dental’s health benefits plans, dental plans (collectively, the Plans). The Plans are required by federal and state law to protect the privacy of your individually identifiable health information and other personal information. We are required to provide you with this Notice about our policies, safeguards and practices. When the Plans use or disclose your PHI, the Plans are bound by the terms of this Notice, or the revised Notice, if applicable.


We are required by law to:

Maintain the privacy of protected health information

Give you this notice of our legal duties and privacy practices regarding health information about you

Follow the terms of our notice that is currently in effect


The following describes the ways we may use and disclose health information that identifies you (“Health Information”). Except for the purposes described below, we will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to our practice Privacy Officer.

For Treatment. We may use and disclose Health Information for your treatment and to provide you with treatment-related health care services. For example, we may disclose Health

Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.

For Payment. We may use and disclose Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment.

For Health Care Operations. We may use and disclose Health Information for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the obstetrical or gynecological care you receive is of the highest quality. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities.

Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and disclose Health Information to contact you to remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may share Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

Research. Under certain circumstances, we may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before we use or disclose Health Information for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any Health Information.


As Required by Law. We will disclose Health Information when required to do so by international, federal, state or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.

Business Associates. We may disclose Health Information to our business associates that

perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Organ and Tissue Donation. If you are an organ donor, we may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.

Workers’ Compensation. We may release Health Information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Data Breach Notification Purposes. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or

missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties.

National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.

Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.


Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.

Disaster Relief. We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.


The following uses and disclosures of your Protected Health Information will be made only with your written authorization:

1.Uses and disclosures of Protected Health Information for marketing purposes; and

2.Disclosures that constitute a sale of your Protected Health Information

Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose Protected Health Information under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.


You have the following rights regarding Health Information we have about you:

Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to Kindra O’Reilley. We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.

Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information.

Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to Kindra O’Rielley.

Right to an Accounting of Disclosures. You have the right to request a list of certain

disclosures we made of Health Information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to Kindra O’Rielley.

Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to Kindra O’Rielley. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to Kindra O’Rielley. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our web site, www.ElementsDentalOfJohnstown.com. To obtain a paper copy of this notice, contact Kindra O’Rielly.


We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a copy of our current notice at our office. The notice will contain the effective date on the first page, in the top right-hand corner.


If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact Kindra O’Rielley. All complaints must be made in writing. You will not be

penalized for filing a complaint.

You may contact our office at:

Elements Dental

848 W. Coshocton Street

Johnstown, Ohio 43031


The Plans may change the terms of this Notice at any time. If the Plans change this Notice, the Plans may make the new Notice terms effective for your entire PHI that the Plans maintain, including any information the Plans created or received before we issued the new Notice. If the Plans change this Notice, the Plans will make it available to you.

Elements Dental’s HIPAA Protected Health Information Privacy Procedures & Training

Our office will limit uses and disclosures of PHI to the minimum necessary to accomplish the intended purposes.

Our designated privacy officer is:

Name: Kindra O’Rielley

Email: Kindra@ElementsDentalOfJohnstown.com

Phone: 740-966-0011

All of our business associates (accounting and consulting firms) will sign a written agreement to ensure confidentiality of PHI (see Business Associates agreement form).

The following administrative, technical and physical s safeguards have been established to protect the privacy of PHI:

Doors are securely locked each evening

Security system has been installed

Computers are password protected

Computers are shut down at the end of the evening

Employees who have access to PHI will receive training in the policies and procedures for the use, disclosure and safeguarding of the information. Training sessions will be documented and kept on file. (See HIPAA Training Form)

The process for a patient to file a complaint is to contact Kindra O’Rielly in writing. Our Compliance Officer will answer the patient’s complaint in a timely manner. If a request is made to inspect and or copy Health Information, we will respond in 30 days. If there is a delay, the Compliance Officer will send a writing statement to the patient explaining the cause of the delay and request a 30 day extension.

If a patient requests PHI to be emailed, and we explain that the email is unencrypted, but the patient insists on receiving their PHI via email, we can email

the information with the patients informed consent.

If a patient requests their PHI in an electronic format, and we only have paper files, we will scan our printed information and send it electronically.

If a patient requests an electronic copy (i.e. a disc) of their PHI, we reserve the right to use a fresh, clean disc that we have purchased (in order to protect our computer system) and to charge a reasonable fee.

If PHI of someone who is deceased is requested, we will disclose requested that PHI to their personal representative.

We have created a document that describes Elements Dental”s information practices and have posted the document in a prominent place where potential patients may see it. We also have paper copies for our patients.

We have posted our Privacy Practice on our website and have made it available in electronic format.

Obtains patients' consent that address the use and disclosures of:

PHI for treatment, payment and health care operations

Protected health information

All other uses of protected health information

We will flag the charts of any patient who does not want their PHI to go to a health care provider.

We will keep a log of uses and disclosures of health information for each patient. (Normal uses, defined as disclosure for treatment, payment and/or health care operations, require a generic log entry.)

We will keep on file for 7 years all other disclosures that require special written authorization.

We will not sell patient information.

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