Patient Forms

Please take a minute to fill out the patient information form before your first appointment:

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Please Read the Follow in regards to our Privacy Policy

BROWNSTOWN FAMILY DENTISTRY; SUMMARY OF PRIVACY PRACTICES

This summary is a condensed version of our Notice of Privacy Practices.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY

We understand that your medical information is personal to you, and we are committed to protecting that information about you. As our patient, we create medical records about your health, our care for you, and the service and/ or items we provide to you as our patient. By law, we are required to make sure that your protected health information is kept private.

How will we use or disclose your information? Here are a few examples (for more details please ask to see the full-length Notice of Privacy Practices)

  • For medical treatment                        
  • To obtain payment for our services
  • In emergency situations
  • For appoint and recall reminders
  • To run our practice more efficiently
  • Ensure all our patients receive quality care
  • For research
  • To avert a serious threat to health or safety

In response to certain requests arising out of a law suit or other disputes​If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. Please contact our office manager for all complaints going through the practice. All the complaints should also be submitted in writing. You have certain rights regarding the information we maintain about you, you will not be penalized for filing a complaint.

You have the right to:

  • Right to inspect and copy
  • Right to amend
  • Right to an accounting of disclosures
  • Right to request restrictions
  • Right to request confidential communications
American Academy Of Pediatric Dentistry