Notice of Privacy Practices

Family Dentistry at Hawks Prairie – Truyen O’Leary, DDS
Notice of Privacy Practices/Acknowledgement of Receipt

Statement of Privacy Practices: We, at Family Dentistry at Hawks Prairie/Truyen O’Leary, DDS, are 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 principle concept of our practice. We may, from time to time, amend our privacy policies and practices but 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 our dental care operations. Your personal health information will never be given to anyone, even family members, without your written consent. You, may give written authorization for us to disclose your information to anyone you choose, for any purpose.

Collecting Protected Health Information: We will only request personal information needed to provide our standard of quality dental care, implement payment activities, conduct normal dental practice operations, and comply with the law. This may include your name, address, telephone numbers, 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 without your written consent.
We may use and/or disclose your health information to communicate reminders about your appointments including voicemail messages, texts, answering machines, and postcards.

Substance Use Disorder (SUD) Information: Although we are not a substance use disorder treatment program under federal law (a “SUD” Program), we may receive information from a SUD Program about you. We may not disclose SUD information, or legislative proceeding against you unless we have (i) your written consent, or (ii)a court order accompanied by a subpoena or other legal requirement compelling disclosure issued after we and you were given notice and opportunity to be heard.

Patient’s Rights: You have the 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. Dept. Of Health and Human Services.

May we discuss dental and account information with any member of your family?                           YES     NO May we discuss dental and account information with any member of your family?                           YES     NO If YES, please name the member(s) allowed:___________________________________________________________________________________________________I acknowledge that I have received a copy of this Notice of Privacy Practices. (You may refuse to sign this). Signature:_____________________________________________________________Date:_________________________
Office Use Only:  We attempted to obtain written acknowledgement of Notice of Privacy Practices but could not because: _____individual refused to sign         _____ (Other )explain: ____________________________________________________