HIPAA OMNIBUS NOTICE OF PRIVACY PRACTICES sets out your rights as a patient with respect to your protected health information.
We have prepared additional forms that are meant to help you exercise your rights as our patient.
Please use the hyperlinks within each description to download the requested form.
Please feel free to contact us by phone for assistance in filling them out.
PATIENT’S REQUEST TO AMEND PATIENT’S HEALTH INFORMATION is to be used by you to change any Protected Health Information (PHI) in our records. We request you use this form when you wish to amend any information about you in our records.
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI) is to be used by you to request a release of copies of your PHI to you, as the patient, or to a third party that you deem necessary. Make sure all required blanks are filled in. Depending on the circumstances, there could be costs involved. Instructions are attached with Form.
REQUEST FOR LIMITATIONS AND RESTRICTIONS ON USE, DISCLOSURE OF PHI is to be used by you if you wish to place a restriction to certain uses and disclosures of your information.
REQUEST FOR LIMITATIONS AND RESTRICTIONS OF PHI IS TO BE USED BY YOU IF YOU HAVE PAID IN FULL FOR SERVICES rendered by TGS Endodontics and wish to limit release of your PHI to your health plan for purposes of payment or health care operations.
REQUEST FOR ACCOUNTING OF DISCLOSURES is to be used by you if you request TGS Endodontics to provide you with a list of those who got your PHI from us.
REQUEST FOR ALTERNATIVE COMMUNICATION is the form to be used by you if you want us to communicate with you by an alternate means or to an alternate location.