Notice of HIPAA Privacy Practices
The government mandates that healthcare providers provide a notice
of privacy practice explaining how patients PROTECTIVE HEALTH INFORMATION (PHI)
is kept private. It is the Health Insurance Portability and Accountability Act
of 1996 (HIPAA). It is important that you read and understand how Verona Cedar
Grove Dental keeps your health information private. Please review this
It is required for you to sign the attached statement indicating
that you have received the Notice of Privacy Practice policy rules for your
Understanding the Type of Information We Have We obtain health information from you and about you when we
(our physicians and staff) provide care to you. This includes your name, date
of birth, sex, demographic information and your health insurance information.
You and other health care providers may provide us with health information such
as your condition, diagnosis and treatment.
Our Privacy Commitment To You We care about your privacy. The information we collect about you
is private. Only people who have both the need and the legal right may see your
information. Unless you give us permission in writing, we will only disclose
your information for purposes of treatment, payment, and business operations
when we are required by law to do so or for other reasons listed below:
Treatment: We may use or disclose medical information about you to
provide and coordinate your health care. For example, we may notify your
primary care physician about the care you receive from us.
Payment: We may use or disclose information so the care you
receive can be properly billed. For example, we may send your health insurer a
bill for your services that explains the treatment you received and why.
Business Operations: We may need to use and disclose information
for your business operations. For example, we may give information to our
billing company in order to collect from you n or your health insurance
We may contact you to give you appointment reminders or
information about treatment alternatives or other services that may be of
interest to you.
As Required by Law and for Other Government Functions: We will
release information when we are required by law or for other government
functions. Examples of such releases would be for law enforcement of national
security purposes, subpoenas or other court orders, communicable disease
reporting, disaster relief, review of our activities by government agencies, to
avert a serious threat to health or safety or in other kinds of emergencies.
Public Health and Safety: We may use or disclose information about
you as necessary to prevent or reduce a serious threat to the health or safety
of a person or the public. For example, we may disclose information about
immunizations and certain diseases to public agencies.
For Research: Any patients involved in research studies will be
required to sign a special consent form before being included.
Family and Friends: We may disclose your information to family
members, friends, or others you identify to the extent it is relevant to their
involvement with your care or payment for your care.
In the Event of Your Death: We may disclose your information to
coroners, medical examiners and/or funeral homes.
With Your Permission: If you give us permission, we may use and
disclose your PHI for purposes you list. You have the right to revoke consent
for PHI disclosure.
Your Privacy Rights You have the following rights regarding your PHI:
Your Right to Inspect and Copy: In most cases, you have the right
to look at or request copies of your medical records. You may be charged a few
for the cost of copying your records. (You may need to make an appointment to
look at your records to assure that we will have it available to you).
Your Right to Request Restrictions on Our Use or Disclosure
Information: You can ask for limits on how your information is used or
disclosed. We are not required to agree to such requests.
Your Right to Request Confidential Communications: You have the
right to ask that we share information with you in a certain way or in a
certain place. For example, you may ask us to send information to your work
address instead of your home address. We will do our best to accommodate such a
Changes to This Notice We reserve the right to revise this notice. A revised notice will
be effective for medical information we already have about you as well as any
information we may receive in the future. We are required by law to comply with
whatever notice is currently in effect.