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30-Nov-2017 06:50

PLEASE REVIEW IT CAREFULLY For purposes of this Notice “us” “we” and “our” refers to the Name of this Healthcare Facility: Mc Clure Pediatric Dentistry and “you” or “your” refers to our patients (or their legal representatives as determined by us in accordance with state informed consent law).

When you receive healthcare services from us, we will obtain access to your medical information (i.e. We are committed to maintaining the privacy of your health information and we have implemented numerous procedures to ensure that we do so.

Notwithstanding anything else contained in this Notice, only in accordance with applicable HIPAA Omnibus Rule, and under strictly limited circumstances, we may use or disclose your PHI without your permission, consent or authorization for the following purposes: Our staff will not use or access your PHI unless it is necessary to do their jobs (i.e.

doctors uninvolved in your care will not access your PHI; ancillary clinical staff caring for you will not access your billing information; billing staff will not access your PHI except as needed to complete the claim form for the latest visit; janitorial staff will not access your PHI).

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We will not condition treatment on you signing an authorization / acknowledgement, but we may be forced to decline you as a new patient or discontinue you as an active patient if you choose not to sign the authorization/ acknowledgement or revoke it.If we do so, that provider will follow the policies and procedures set forth in this Notice or those established for his or her practice, so long as they substantially conform to those for our practice.



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