AUTHORIZATION

I authorize the dentist to perform an examination, diagnostic procedures and prophylaxis as may be
necessary for proper dental evaluation.

• I authorize release of any information concerning my (or my child's) health care, advice and treatment
  to another dentist.
• I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise
  payable to me for services rendered.
• I authorize the use of this signature on all insurance submissions.
• I authorize the dentist to release all information necessary to secure the payment of benefits.
• I understand that I ant financially responsible for all charges whether or not paid by insurance.

NOTICE OF HIPPA PRIVACY PRACTICES

HELLO DENTAL
2085 East 27th Street
Brooklyn, NY 11229

This notice discloses how medical information about you may be disclosed and how you can get access to this information.

PLEASE REVIEW IT CAREFULLY

Who will follow this notice?
In keeping the provisions and requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), this notice
describes HELLO DENTAL health care practices regarding your protected health information. It applies‐to all employees, students and
volunteers authorized to give, receive, or share your health information for treatment, payment, or regular health operation purposes
described in this notice especially our duties to you regarding your health information.
"Protected health information", (PHI) is individually identifiable information expressed in the form of oral, written or electronic
communications. Our establishment is required by law to:
(1) Make sure your, PHI, is kept private at all times.
(2) Give this notice of our legal duties and privacy practices in relation to the use and disclosure of your PHI.
(3) Follow the terms of the notice currently in effect.
(4) Communicate any changes in the notice to you.

Your rights regarding your health information
Although your health record is the physical property of this clinic, the information belongs to you. You may take any of the following
requests to HELLO DENTAL. You have the following right regarding your protected health information (PHI).

1. Right to inspect and copy: You have the right to inspect and obtain a copy of your records: This PHI, for as long as we maintain your
health records. This does not include information compiled in anticipation of, or use in civil, criminal or legal proceeding; and PHI that is
subject to law that prohibits access.

2. Right to request amendment: If you believe the health information we have about you is incorrect or incomplete, you may ask for an
amendment, change or addition to be made. We may deny your request if we believe the information is not part of the health information
kept by the business, or is not part of the information you would be permitted to copy.

3. Right to Accounting Disclosures: You have the right to an accounting disclosure. This a list of where we have sent your health
information but does not include disclosures made for treatment, payment, or health care operations as described in this notice. Your
request must state a time period beginning on or after April 14, 2003 and end no more than 7 years from date of request.

4. Right to request Confidential Communications: You may request that we communicate with you using alternative means or at an
alternative location.

5. Right to request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about
you for treatment, payment or health care operations. We also have the right to deny your request.

You may submit your request in writing to:

HELLO DENTAL
2085 East 27th Street
Brooklyn, NY 11229

How we may use and disclose your health information: The following categories describe different ways that we use and disclose your
protected health information, (PHI).
Required Uses and Disclosures: By law we must disclose your health information to you unless it has been determined by a medical
professional that doing so would be harmful to you: If requested we must disclose your health information to the Secretary of the
Department of Health And Human Services (DHHS) for investigations or determination of our compliance with laws on the protections of
your health information.
Treatment: We may use your info nation to provide you with treatment or services. This includes recommendations to specialty care
physicians and lab technicians providing auxiliary care.
Payment: Your health information will be used to bill and collect payment for services provided to you. We may share this information with
your health insurer or health plan to get approval for payment.
Health Care Operations: We may use and disclose your health information for regular health care operations with contracted third party
"business associates" who perform various activities for the clinic.
Required by Law. We will disclose your health information when required by federal, state or local law and or law enforcement officials to
do so.
Parental Access: We will act consistently with the law and make only necessary disclosures of protected health information to parents,
guardians, and persons acting in similar legal status.
Individuals Involved In Your Care: We may disclose health information to notify a family member or personal representative of your
location, general condition or death.
National Security and Intelligence Activities: We may disclose your health information to authorized federal officials for intelligence,
counterintelligence and other national security activities authorized by law.

I do acknowledge having read and signed this document and do agree to the terms and conditions of this HIPAA.