HIPAA Notice of Privacy Practices
Our Privacy Pledge: 

We want you to understand that we respect your privacy. Other than the necessary uses and disclosures we describe below, we will not sell your health information or provide any of your health information to any outside marketing company. 
Uses and Disclosures: 

Below you will find examples of how we may have to use or disclose your health informantion: 
1. Your doctor or staff member may have to disclose your health information (up to and including all of your clinical records) to another health care provider or a hospital if it is necessary to refer you to them for diagnosis, assessment, or treatment of your health condition.
2. It may be necessary for our insurance and/or billing staff to disclose your examination and treatment records and your billing records to another party, such as insurance carrier, your employer, a family member, other relatives or close personal friend, who is involved in your care or to facilitate the payment related to your care. 
3. It may be necessary for the doctor and members of the staff to use your health information, examination, treatment records, and billing records for quality control purposes or for other administrative purposes to effectively run our practice. 
4. Your doctor and members of the practice staff may need to use your information (ex. Name, address, phone number, and your clinical records)  to contact you to provide appointment reminders, information about treatment alternatives, or other health related information that may be of interest to you. If you are not at home to receive an appointment reminder, a message will be left on your answering machine. You may inspect or copy the information that we use to contact you. 
As our patient, you possess the right to refuse to give us the authority to disclose this information. If you refuse authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care. 
I understand Pace Dental has the right to change its Notice of Privacy Practices from time to time and that I may have contact Pace Dental at any time to obtain a current copy of the HIPAA Notice of Privacy Practices. 
I authorize the following person (s) to receive information on my behalf when/if necessary.