As dental professionals, Dr. Lee and her staff implemented this Health Information Privacy Policy and Procedures to protect the interest of our patients and to fulfill our legal obligation under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the amended modifications of 2002 and state law that provide greater information are important to us. We will not use your health information for marketing communications. We may use your health information:

• · To other dental specialist to who you are referred
• · To provide you with appointment reminders
• · To you or to anyone you designate in writing
• · To obtain payment for services we have provided for you
• · When required by law

As a patient you have a right to view or transfer your dental records.

If you want more information about the privacy practices of this dental office, or if you are concerned that we may have violated your privacy rights, please contact our office or the U.S. Department of Health and Human Services.

We support your right to the privacy of your health informaion.

Contact officer:
Susan H. Lee, D.M.D.
3280 Howell Mill Rd., N.W.
Suite 121
Atlanta, GA 30327
Phone: (404) 355-8557
Fax: (404) 355-8321

 

If you wish to print this form for your records, you may download a copy here.

 

Acknowledgement of Receipt of Notice of Privacy Practices

** You May Refuse to Sign This Acknowledgement **

Acknowledgement of Privacy Policy

I am the "personal representative" of (generally parent of legal guardian) and the the legal authority to make health care decisions about the following minor patient:

Please Type Patient's Name:*

I have received a copy of this office's Notice of Privacy Practices.

Type Your Name:*

Type Today's Date:*

Authorization for Additional Disclosure

I authorize the following individuals to accompany my child and have access to health information.

Contact 1

First Name:

Last Name:

Relationship:

Contact 2

First Name:

Last Name:

Relationship:

Contact 3

First Name:

Last Name:

Relationship:

 

Re-Type Your Name:*

Re-Type Today's Date:*