Notice of Privacy Practices

Purpose: This form, Notice of Privacy Practices, presents the information that federal law requires us to give our patients regarding our privacy practices.
We must provide this Notice to each patient beginning no later than the date of our first service delivery to the patient, including service delivered electronically, after April 14, 2003. We must make a good-faith attempt to obtain written acknowledgement of receipt of the Notice from the patient. We must also have the Notice available at the office for patients to request to take with them. We must post the Notice in our office in a clear and prominent location where it is reasonable to expect any patients seeking service from us to be able to read the Notice. Whenever the Notice is revised, we must make the Notice available upon request on or after the effective date of the revision in a manner consistent with the above instructions. Thereafter, we must distribute the Notice to each new patient at the time of service delivery and to any person requesting a Notice. We must also post the revised Notice in our office as discussed above.

Addendum to Notice of Privacy Practices
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THIS ADDENDUM TO THE NOTICE OF PRIVACY PRACTICES SETS FORTH WISCONSIN PRIVACY REQUIREMENTS THAT ARE IN ADDITION TO THOSE IN OUR NOTICE OF PRIVACY PRACTICES.
PLEASE REVIEW IT CAREFULLY
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THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
We are required by Wisconsin law to maintain the privacy of your health information.

USES AND DISCLOSURES OF HEALTH INFORMATION

Healthcare Operations: Under Wisconsin law, we must have your written permission before we may use and disclose your health information in connection with healthcare operations other than management of our medical records and certain auditing and review activities by staff committees and review organizations.

To Your Family and Friends and Persons Involved in Your Care: Under Wisconsin law, we must have your written permission before we may disclose your health information, other than limited identifying information, to your family, friends, or other persons involved in your care.

Abuse or Neglect: Under Wisconsin law, we must have your written permission before we may disclose your health information to the appropriate authorities if we believe you are the victim of domestic violence or other crimes. We may report child abuse and the abuse or neglect of a vulnerable adult as allowed by Wisconsin law.
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PATIENT RIGHTS

Restriction: While we are allowed to determine whether we agree to your request to restrict our use and disclosure of your protected health information, Wisconsin law requires that we honor certain restriction requests by private pay patients relating to research or the release of information to government agencies.

Contact Officer: Heather Van Natta
Telephone: 608/437-5564
Fax: 608/437-8790
Email: heather@familydentalcarellc.com
Address: 522 Springdale Street, Suite 101
Mount Horeb, WI 53572