JUST FOR KIDS DENTISTRY KEVIN SAKAI DDS PUYALLUP OFFICE

234 CMR BOARD OF REGISTRATION IN DENTISTRY 234 CMR
A GUIDE TO IMPLANT DENTISTRY PART 2 SURGICAL AND
ALEXANDER KISTER UNIVERSITY OF MEDICINE AND DENTISTRY OF NEW

CARDIFF UNIVERSITY SCHOOL OF DENTISTRY DENTAL SCHOOL RESEARCH ETHICS
DENTISTRY TERMS 1 ABRASION 2 ABUTMENT 3 ALVEOLAR BONEALVEOLAR
DEPARTMENT OF ORAL BIOLOGY FACULTY OF DENTISTRY SEMMELWEIS UNIVERSITY

Kevin Sakai D

Just For Kids Dentistry

Kevin Sakai D.D.S.


Puyallup Office: 311 River Road Suite 201 Bonney Lake Office: 20811 Wa 410 E

_____________________________________________________________________________________________


NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT


The effective date of this notice is April 14th 2003. (HIPAA) It will remain in effect until we replace it. This Notice pertains to you and your child/children/legal dependants.


At Kevin H Sakai, D.D.S. PLLC Just for Kids Dentistry Puyallup & Bonney lake Offices, we keep records for all dental/medical services that are provided for your children and or legal dependents. You have the right to review this information (protected Health Information= PHI) and to request copies of this information. We only charge you a reasonable fee to duplicate and assemble theses copies. You also have the right to request modification of any incomplete or incorrect records. Modification request are required to be presented in writing. Our office will not disclose your child/children’s or legal dependents records to others unless directed by you or unless law authorizes or compels us to do so.


Our Notice of Privacy Practices details how your child’s/children or legal dependents dental/medical information may be used and disclosed by our office.


.. Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly.


.. Obtain payment from payers for my health / Dental care services.


..Conduct normal health care operations such as quality assessment and improvement activities.


Additional Disclosure Authority


In addition to the allowable disclosures described in the statement of Privacy Practices, I Hereby specifically authorize disclosure of my protected health information to the persons indicated below.


Spouse Only: [ ] Yes [] No Other: [] Yes [] No ( Please Specify)_________________________________________________


By my signature I acknowledge receipt of this notice of Privacy Practices: For the following Child/Children


Please Print Clearly and Use Legal Names ONLY


____ ___ __ ___________ ______/______/______ _________________________

Child’s First Name M. Initial Last DOB your relationship to this child


____ ___ __ ___________ _____/______/_______ _________________________

Childs First Name M. Initial Last DOB your relationship to this child

____ ___ __ ___________ _____/______/________ _________________________

Child’s First Name M. Initial Last DOB your relationship to this child


____ ___ __ ___________ _____/______/________ _________________________

Child’s First Name M. Initial Last DOB your relationship to this child


____ ___ __ ___________ _____/______/________ _________________________

Child’s First Name M. Initial Last DOB your relationship to this child


____ ___ __ ___________ _____/______/________ _________________________

Child’s First Name M. Initial Last DOB your relationship to this child


________________________________ _____-_____- ______

Parent / Legal Guardian Signature Date


____________________________________________________________________

Print Name

THIS FORM WILL BE RETAINED IN YOUR CHILD’S/CHILDREN’S/LEGAL DEPENDENTS DENTAL RECORDS.


DIPLOMA IN RESTORATIVE AND AESTHETIC DENTISTRY C19C26 ASSESSMENT DECLARATION
DR DAVID KEEN WWWKEENDENTISTRYCOM 6194420983 CAMBRA MODERATE RISK
GDC POLICY STATEMENT ON RESTORATIVE DENTISTRY AND THE SPECIALTIES


Tags: dentistry kevin, kids dentistry, kevin, office, dentistry, puyallup, sakai