Dr. Cynthia Paquette
  • Services
    • General Dentistry
      • Sleep Apnea
      • Consultation
      • Prevention
      • Emergency Care
    • Cosmetic Dentistry
      • Teeth Whitening
      • Porcelain Veneers
      • Composite Fillings
    • Restorative Dentistry
      • Metal-free partials and dentures
      • Dental Implants
      • All Ceramic Crowns and Bridges
      • Intraoral scanner
  • About
    • Practice overview
    • Meet The Dentist
    • Dental FAQs
    • Smile Gallery
  • Contact
    • Our Location
    • Patient Forms
      • Patient Forms
        • Dental & Medical History Form
        • Dental HIPPA Form
    • Team members
  • HEADACHES
  • INTERESTING EXTRAS
    • Fluoride Good or Bad?
    • All Natural Dog Toothpaste Recipe
    • Vietnam Volunteer Trip
    • Homemade Cat Toothpaste
    • Opening hours
    • Featured services
    • Testimonials
  • SEDATION
    • Nitrous Oxide
    • Prescription Medication
    • AROMATHERAPY
  • Oral Health
  • Terms & conditions
  • Home
  • Account
  • FORM 1
Dr. Cynthia Paquette Dr. Cynthia Paquette
Dr. Cynthia Paquette Dr. Cynthia Paquette
  • Services
    • General Dentistry
      • Sleep Apnea
      • Consultation
      • Prevention
      • Emergency Care
    • Cosmetic Dentistry
      • Teeth Whitening
      • Porcelain Veneers
      • Composite Fillings
    • Restorative Dentistry
      • Metal-free partials and dentures
      • Dental Implants
      • All Ceramic Crowns and Bridges
      • Intraoral scanner
  • About
    • Practice overview
    • Meet The Dentist
    • Dental FAQs
    • Smile Gallery
  • Contact
    • Our Location
    • Patient Forms
      • Patient Forms
        • Dental & Medical History Form
        • Dental HIPPA Form
    • Team members
  • HEADACHES
  • INTERESTING EXTRAS
    • Fluoride Good or Bad?
    • All Natural Dog Toothpaste Recipe
    • Vietnam Volunteer Trip
    • Homemade Cat Toothpaste
    • Opening hours
    • Featured services
    • Testimonials
  • SEDATION
    • Nitrous Oxide
    • Prescription Medication
    • AROMATHERAPY
  • Oral Health
  • Terms & conditions
  • Home
  • Account
  • FORM 1

20609 11 Mile Rd.

St. Clair Shores, MI 48081

586-774-8090

Call us today!

Opening Hours

Mon: 9:00-5:00 Tue: 10-3:00 Wed: 11:30-6:00 Appointment Only: Fri/Sat

Book Appointment

cynthia9533@att.net

Dental HIPPA Form

  1. Home
  2. Patient Forms
  3. Dental HIPPA Form

















 

DENTAL HIPAA FORM Logo
  • DENTAL HIPAA FORM

  • The Health Insurance Portability and Accountibility Act of 1996 (HIPAA) requires that health providers keep your medical and dental information private. The HIPAA Privacy Rule states that health providers must also post in a clear and prominent location, and provide patients with, a written Notice of Privacy Policy.

    1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other that office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient record, and other documents or information.

    2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e­mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.

    3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access the pateient history information but must agree to abide by the confidentiality rules of HIPAA.

    4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.

    5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.

    6. Your information will not be used for the marketing purposes or advertising of products, goods or services.

    7. We agree to provide patients with access to their records in accordance with state and federal laws.

    8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.

  • I,       , hereby consent and acknowledge my agreement to the terms set forth in the DENTAL HIPAA FORM and any subsequent changes in the office policy. I understand that this content shall remain in force from this time forward.
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20609 E 11 Mile Rd.

St. Clair Shores, MI 48081

586-774-8090

Call us today!

Opening Hours

Mon - Tues: 8:00 - 3:00 Wed: 11:00 - 6:00 Fri-Sat: By Appointment Only

Appointment Booking

cynthia9533@att.net

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