Signature will be recorded later.
Capitola Dental · P|831-475-2313 · 617 Capitola Ave, Capitola CA, 95010 · · www.capitoladental.comDate: 8/4/2020(last name)(first name)Dr. Robert C. Schellentrager DMD General and Cosmetic DentistryNotice of Privacy PracticesThis notice of Privacy Practices provides information about how we may use and disclose your medical information. The Health Insurance Portability & Accountability Act (HIPPA) is a federal program requiring that all medical records used or disclosed by our office be kept confidential. We are required by law to maintain the privacy of your medical information and to provide you with notice of our legal duties and privacy practices. HIPPA requires us to notify you that we may use your medical records for each of the following purposes: treatment, payment, and health care operations. Only with your written authorization will any other disclosures of your medical records be made. - Treatment is providing, coordinating or managing your health care and related services. - Payment is obtaining reimbursement of services, confirming insurance coverage, billing and collection activities and utilization review. - Health care operations include business activities or management of our office. You have the following rights regarding your medical records: - You may request restrictions on disclosures of your medical records. - You may review your medical records. - You may request a copy of your medical records. There may be a charge for this service. - You may provide an amendment to your medical records. - You may request a list of disclosures made from your medical records. This notice is effective as of 4/12/2012. We reserve the right to change our privacy notice. If you feel that your privacy protections have been compromised you may contact our Office Manager or the Department of Health & Human Services or the office of Civil Rights.I,Acknowledgement of Receipt Form, have received a copy of this office’s notice of Privacy Practices.