We are committed to protecting the privacy of our patients. Here are some of the policies and procedures we have in place to guarantee the safety of our patients’ information.

How We Protect Our Patients’ Privacy

Portland Smiles (PS) is committed to protecting the privacy of our patients. We have specific policies that address the way health care information and other personal information is collected, used and disclosed.
PS obtains information that is necessary to determine medical health and dental benefits. This information is received by mail, in person, by telephone and electronically. It is protected by our secure building, secure electronic systems, and by PS associates’ commitment to the terms and conditions of our confidentiality policy. Health care and personal records are accessed only by associates whose specific jobs require them to do so.

Health care and other personal information is not disclosed to or exchanged with third parties without authorization, unless its disclosure or exchange is necessary to determine benefits, comply with legal or regulatory requirements, or to permit PS to perform routine business activities.

Consent to Portland Smiles Use of Health Care and Personal Information

In order to provide health care coverage to our patients, we ask patients to authorize release of personal information necessary to carry out our legitimate business purposes. PS requests that the authorization for release be signed by the applicant, the applicant’s legal spouse, and any other dependent 18 or older. In instances where the patient is unable to provide consent, an authorized representative may provide consent on behalf of the patient.

PS may contact the patient with appointment reminders or to provide treatment alternatives at the provided address and telephone numbers.

Patients’ Right to Access and/or Supplement Personal Information

Upon written request, PS will permit a patient or a patient’s authorized representative to see and copy, or obtain a copy of, any recorded personal information about that patient held by PS that is reasonable described and can be located and retrievable, within 30 days of the request. A written request may also be submitted to correct, amend, or delete any recorded personal information about that manner held by PS. PS will notify the patient if it will or will not comply with the request regarding what is the correct, relevant or fair information.

Consent Form

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by Portland Smiles of our Notice of Privacy containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

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