YOUR PRIVACY IS IMPORTANT TO US

THIS IS A REDUCED VERSION OF THE REQUIRED PRIVACY NOTICE. THE FULL VERSION IS SEVERAL PAGES LONG AND IS AVAILABLE TO YOU. YOU MAY REQUEST THE COMPLETE PRIVACY NOTICE AT THE RECEPTIONIST IN THE OFFICE.

*You May Refuse to Sign This Acknowledgement*

 PRIVACY NOTICE

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Privacy Notice is being provided to you as a requirement of a federal law, the Health Insurance Portability and Accountability Act (HIPAA). This Privacy Notice describes how we may use and disclose your “protected health information” (PHI) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI in some cases. Your PHI means any written and oral health information about you, including demographic data that can be used to identify you. This is health information that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition.

Contact Person: The facility’s contact person for all issues regarding patient privacy and your rights under the federal privacy standards is the Privacy Officer. Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer as follows:

Privacy Officer: Christina Smith

Telephone: 337-500-1500

Email: lesliejacobsdds@gmail.com

Address: 113 Rue Fontaine, Lafayette, La. 70508

 

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

I acknowledge that I have received the attached Privacy Notice from Dr. Leslie Jacobs Pediatric & Adolescent Dentistry.

Your Signature