Notice of Privacy Practices

Effective February 26, 2005

This notice describes how medical information about you may be used and disclosed, and how you can access this information.

This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). It describes the limits to which we may use or disclose your protected health information, with whom that information may be shared, and the safeguards we have in place to protect it. This notice also describes your rights to access and amend your protected health information. You have the right to approve or refuse the release of specific information outside of our system, unless the release is required or authorized by law or regulation.

Contact Us

For further clarification of our Notice of Privacy Practices, you may send e-mail to
PrivacyOfficer@amddentistry.com or call (206) 464-9002. You may also write to:

Advanced Metropolitan Dentistry
Privacy Officer
1220 Howell St., Suite 160
Seattle, WA 98101

Additional Resources

U.S. Department of Health and Human Services
200 Independence Ave. SW
Washington, D.C. 20201
www.hhs.gov

Acknowledgment of Receipt of this Notice

Each patient is asked to sign a consent form referencing this notice. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. However, the delivery of your health care services will in no way be contingent upon your signed acknowledgment. We will provide you appropriate care whether or not you sign the form.

Who Will Follow This Notice

This notice describes Advanced Metropolitan Dentistry (AMD) practices regarding your protected health information.

Our Duties to You Regarding Protected Health Information

“Protected Health Information” is individually identifiable health information. This information includes demographics, for example, age, address, e-mail address, and relates to your past, present, or future physical or mental health or condition and related health care services. Advanced Metropolitan Dentistry is required by law to do the following:

• Make sure that your protected health information is kept private.
• Give you this notice of our legal duties and privacy practices related to the use and disclosure of your protected health information.
• Follow the terms of the notice currently in effect.
• Communicate any changes in the notice to you.

We reserve the right to change this notice. Its effective date is at the top of the first page and at the bottom of the last page. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. If you would like a printed version of this notice, ask for a copy at your next hospital visit or clinic appointment, or click on the link below to download the document in its entirety.