Just For Kids Dentistry
Kevin Sakai D.D.S.
Puyallup Office: 311 River Road Suite 201 Bonney Lake Office: 20811 Wa 410 E
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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
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