400sN ilrrtrtlrrg Ha.tIrFR.lrtrd srnrh.3: YUe witt not uss )rauf hcairt

400sN
AIID
THIS ilOTICE DESCRIBES }IOW HEfiJTH INFORiIATIOI{ AEOUT Y(R' MAY 8tr USED
lIlf,lORiltATlOIt,
THIS
TO
DlsctosED AtrE HOU' Yo|l CIIU BET AOCESS
PLEAST RN'IEU IT GANEFULLY.
THE PRIVACY OT YT}UR HETXTH IITIFORII'TTIOH IS IMPOR'TAilT TO Us.
OIJR TIGAL DUW
Vrre BrB requk€d by amllcable $sdaral and salB laff to malmaln the privccy af ltur h€8lth infrmation. \AI€ ara ai$o
requlred to givs you rhis l.loii€s about
fivrcI Factlcs. our qal drElss. and Jour rBBr$ concerning your hesfth
informatlo{]. WE rnust follil, th8 fivac} practicss rhst ara dassiled in this ilfih€ whlls it E in etFsct. fhis Notics
. and will rernain tn effect untll nre rep,a* lt.
td<es etrect ,A4l
sr
t4",et
We raserue the right to changa 0w prlvacy pr€$lces ard tha tarms ot thtr lt'lotCe et ony firna, pr0vided such
changps are psrniEed by applicabte law. \l/r reseru th* right to make the ehangps ln our trlv8cy prafiicss and the
narrc:enTrs of our Notica ettst\ae for slt hEtth ifftrrnatlon that tve m5intsin. including haalth infomgtion \,€ cr€al'
ed s recs$ed bafore ,r,e made rhe changee. Bar&re we make a signiticEnt chEngts in il,rr priY8cy practlcE' we will
change ftG Ndica ard m8l€ the nelv Notb* ar8ilsblg upon r€que6t.
mayreq.resr E copyoFo{.r f\hrice gt Errytirns For rnore inbrrn tton rbout fiir privac} prEctic6q or for sdditioncopi6 ofthb f.Ici6, peasa corrtact us usirg the tnrornntbn listed ilthe end of this Notice.
Yo{"r
ef
I.lSEs AI{D DIIiGLOSUNES OT HEALIH IT{fOMATU}TI
llb usa and disdsss ltsaEh iniofrrlstisr abo'rt yorr lbr reafiler& p8lrnant 8t?d hB8lthcEfe speratti}ns. For example:
Trrrtmqnt: Wa ma! usa ar disclose your heatth info,rrnation to a phlslcian or other heal81care prmider p,to'
vidlng trestment m !,ou.
P.)Emm: \irre may use and disclme yo.n heal$ lnfonnetion lo olt8iir peymart fa ssrvlogs wa pruArtds to you
gil
anddisclseyour hsskfi irfrrmsticn in ccnnection wlth our heatthcara oper'
qusiitl
include
asssssfi}Btt 8rH imprcrement adivi$es. reviawlsg th8 comPetenca 6t
a*ons. Heahhiare operations
quallficatiofis o( heslthcsr8 professianals, €,nralusring praditlonar afld pranider perlOrmanrA conduc,ting ttainirg
trograms. accrditsiiorl, ffirificatlon licansing of crederElcling sctivitles.
)halt
oF|fi.dolE: liib
rnay use
Vrr &rthodrtlon: ln adda$on to otjf uss cf ,olr healtfi lnlfirnstion fo'raarmE* Fymert or healthcare apera'
to disclose it to €n:pne,ftr any plr'
$ons. )o{J may glve ijs *rin€fi autfiariuBti(p1 to uie ysrr h€alth informftion
yrlting
Ys.r
you
rsocatim will nol af€ct any us8
rEvoke
it
8t
rna)r
lfi
Enytime.
pce f fou give us sn auttrsEati$n.
b Oiscfis.ree psnnlrcd by ycrr authoriirtion *tlile lt yrEi in €trEct" Unhss yo{.r gise us a wrfttsfl aurhof iatior). w€
cafift61 us6 or dtscfose you-r ireahft inforrnaisr ftr any reason BrcEFt thtse described ln this I'lobe'
r
you F.'ntty end Ftlrndr: We must discloso lfour heaEh lnformation to !ou, as describad ln the htient
prswt
Rigtrts secrion if ttis Nauca \tle rnay discbse yor.rr health lnftrmation lg I farnily rfismber, Fiend.or ml}er
To
to tfre extant ncc6sary to hatp wittr your
we may do so,
tnghniare or '*irn psymsnt for your haa*ftcsfle, but anly
af
lalu agree tfiat
lnnow tn C.tt: t{e may uss or dlscloqe heath informsrion to no(ify, or asslst in th€ notificarion of
(inciuding identi$lng r loca$ngi a firnity msmbsr, Jsur personal r€FrBsenmlhrG or anofihel peI3on respon3iE{s for
your ca;a oryourimauon yorlureraf cinoitlon ordeatir. lf you are presarn. tfEn prior to LFa or disclosure of )ew
your
heaErl infurm$ion. uE wifl hoydeya.r w;rh an oprtuniry ro oQiecttg suctt us.ls of discloss*. ln the anent of
aw
tncapocit, or efnergency c'fculvtstbnces. \,ug wi[ disClose heatst informmicn h€s€d En a il€rteilrrinBtion uslng
pur
ln
persqrb
iilvol€ment
to
tho
r€tamrt
is
dtectty
frafesr:oneUr.d$n€rn disdosfg only ireehlr irfonnsuon $at
iuaurcare. frOiirr rlgo u$e our-protisslonagudgrnentandcEr exprdnc* with ctrnmofi practlcBBm6hareason'
sr
aHe inf€ferces ff)our bes! lni€rBsl in 5l]6tring apsrsst ro pick up filled pfescriFr,ons, ndical supplie*. x'ra!&
dfEr slmilar forrfis 0f heahh inlsmaricn'
ilrrtrtlrrg Ha.tIrFR.lrtrd srnrh.3: YUe witt not uss )rauf hcairt information fof rlErk$irg communications
Prrronr
lYithsul,tilr wrnen al..[ltrizatlon.
mcnCnd by
lrll;
We may use or discloGe yo{.,r |resfth irlionnation }ufier n e
ra
regutre{t rc do so hy
lErA''
t ve reasofiabl! b6li6t/€ $at
}Et.r h€ekh lnfurmation to apFlropriate authorid$ if
dhg.c4mg3 Wemaydis'
vi"2im6f
youareapofslUleviAim4'sUrso. reil#"f mme5filcYiobrce#tfiaposslof
g ssfety * gis health
pur
hes'tft
to
a
ssrieu$thrEat
receoay
to
extent
to
tnftrrratton
ths
heath
Ah|!r or togl*s tf& may dtsclaEe
ctose )Dur
or
safttI 6, dhsE.
"t*a
lhdonrl Sranlry: tlb
discloca to rnilitarl aufiorirk the heahh infiorrnffiorl of Armed Forces pcrsonnel
under
lnay
cefiain circuneances" l/tle may. disclose to authoriaed Herat ofitcials lmltfr tff?rm$ion
rqulred
lslyful tfte[i.
Idligsnce. 8Id othrr na$onal socrnity acirlties. We may dislose to enectisn6l lmtltjnion or law
enhrcemtrt offcial having lawful ctrmayorprrceo h6lth inform$ton tr*nata s patteflt unfr
ctrtaln
il
*
'srancles,
lgeotr*mrnt Rrrtndur:.I{b
may usB or disclo6eyujr hsslrh informstion to proylde
}ou u,lth appolntment
is$ers].
rsmhders tsuch asvoic€nu[ r?r€Esag6q poscrth.
PATIE]TT
clrcum,
*
REHNi
hEEti€rightlogol(Sorscopitcofyorrheatth
$ry:Jut
rsql.Gst that rG
copic in formst
lnarmatkln.wtrh firniredexceBtons. you may
rodcle
a
cter ttran prruocoples. Wb wlll rss tha formst lou requ€st unless we
cannd Practicebly do sa flbu must male a reqr.n* in rffitirg to o&ah accss
to Jpur heahh lnhrrng1bn you maSr
ob,tain a brm to requQot
by rlrlrg the c*rnct irfamation llsmd $ fie Erd iS US filoricE. Wb
wlu chargie
T6Ss
areeonslemt'basdfuefuraearsegglclt fficspi€sardsrsfitimE. th.r malratso req.reeaccessbysendlngJuJ
us
a len€r to thB Ed&Ess e the end of this l\&otice. lf
3ra.r request optes. bvq wiil cllarye pir EO *
r# eacn p"g*.
. ps har f6 sfefftime to locale ard eopyyour nairtn hrormsrbft and poerage
uen fr6 mp]as maited
tgfol' lf p1 rEqrr€st 8n ahernerilE forfi!8t, un witi ctnrgEa mctlwo ree ror proi rngryou
prt
hesth lrformation in
thd ffiet' lf pr prelF, wa will prePsm a summary or an setanation d y"* r["rtn i"ilrnai".
ru a ir". Conro
us using tfe ir{ffion lisiled Er tfte end of rh}s N*ice lbr a iun exptanaobr
d qrr fee $rtrc&n6.)
l!?tGT. ATaIIInS Yrru hary fie right ro rsceiue a ll$ or insnces tn which w6 or our businss sssociatcs
.disclosadyourhaalth lnform5tlm frpxpoaes, dh€rthanrmtrrert. puyn*r h€$Eareop€rsilgrEarx,certain
dhEradt$itlea fiortlrelastSlers. h* rsha*oreAPr,l r{ &t. rpurequesrtnisaccourCIrfir"*;d"
mse tn a
l2-montfr pcrld. n€ rmy cfage yur I reaslabb. cosr-aeseo teix resiooatng to trrese
aaiitionat rgqu€615.
310'@
R.tffibn:
haw th€ ilgftt to rBquast thst wc plaes addirionsl rsstrictions on our use {r disclosure of
}our
b{.rt if yve da sEwiu abide tryour
agreement (mepr lnan enrergeney).
1bu
hekh inturnatbn. lltbre nu.rqutrEd&agreeCIttmedditlcnsl re.sirlct*rrc.
llunatrrGmrJcrdar:Yo.rtwetnrlgftmr€+restttmnccuwrunlcatewirth]@r abour)Eurtealth lrfrrmation by alternath,B rn*ans tr to ahern&he loEatiCIrc. {lh.r rnusr mab
)plr r€qLEEr tn-urtttrg.} }6,urueq,reur -u.r
Secify sts ahernsthrq means s lffihn antt prnvitle satifuory exprarhron nor paynpnts iilt be handtsd unoer
fie alte.natiiB rrreaflE or locatiqr pu rqu€$.
Amrdmc lbu hsrc fre dght B rq:es dret ure amerd prr health ln&rrutlon. [bur rques mu* he ln lrniting[
srtd
ltmu*eilphin rvtUthe inromsion struH
flrcrronre
be amsrded.)
lifumaf denylourrsqrte$,undercstinctrcurrEtances.
l{xlcr: lf }ur receiva this Notice on our trleb sirp or by ebciroflic mail
reeil8 this r{oth8
ln
unitffii funn
qrEsrpils rto cuunrmni
lf you want more lnhrrr}Ettort oborrt or:r
prltaqr prmlrces
c iale euesrlcns
(e,mait}. you are entitled to
or conc€fitsi, ple6s€ confttct us.
trpu aecancernert*wvm mayhennvloiut$your pfivwlrigtG, rycnr disageawith a deqlsionrygmade Bbot$
eeess b your fl€sl& inrumation or in rssponse to a rsqJost lot nraoi to arnslo or rslcr $e use or dkbsure of
yotr h€3lth infrma$on r to here us comrflunlcat€ whh
1ou by atternxlw ilEens rr Et alttrrmtiue tocations. yo{r
tnay wnplaln E us using thB contact inhrmxion llstcd Bt ttB and of thls Notlce. You alsa may subrrrlr a v,ntien
complairt ts t}le U"S.
,Oeprtmer* of Fhalrr and Hunrarr Seruies. t{b rvtx pouide you wtth ttre adtress b file yow
ffir$aiffxd$fio U.S Aeparuemd Fhakh arrd Hurnanservles upon rirqr**
lth spportlour rlghttotlte pdvacydlo'ur heslth infonnathn. tthwlil n6trets[5t6 In anyway lf pu chooseto flle
a cornplatra Yrkh
Leq with the
o*r*o'r.s_
fe*ptlrye {O(P}
E
rndt
Adgre
a
z08€68
4@ N.gWArc
U.S,
Depnreflt
(no(
t
of Haahh erd Huraan Servtces
t<+_?* oi
r*
*
-.
.
-
tr6.P75
€$, g.\ eqYiill<g {Q g.t^,,..l ,ra p\
(302)
Phoanbr, AZ 85017
XElnctrn llarr lcuur
A[R.giBRlroftil.
emnnhnudtrdtll!kflb}tEtdlauddtr.sFBlirrnilqtrfrydt rGen#icll6rr&ru$hnd$r!tx!nEllrcrBFrryroquro.gtap.rs
5!rr Tp,arlaafiltLilslry! Doil.l Lsodrlrr
Ufi futnlrdsEral onu,6.rUcoilrdt,DLgJ..Xq, fds:tontthr,
rBiEr,mSu$ald q.
Especialidades Dentales
-
Gopi Kapadia D.D.S. 4008 N. 33'd Ave
- Phoenix,
AZASO|T
ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
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American Dental Associaiion
All Rights Reserved
@ 2002
Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires
the prior written approval of the American Dental Associat,on.
This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).