QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice.  You also may submit a written complaint to the U.S. Department of Health and Human Services.  We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information.  We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer:   Kathy Wenger                                                                                                                                                       

Telephone:  (717) 653-8177                                                             Fax:   (717)653-6142                                                         

E-mail:                                                                                                                                                                                                  

Address:  420 Cloverleaf Road           Elizabethtown, PA  17022                                                                                              

 

Please Print or Type your name Here:

 

 

Please Sign and Date Here: ____________________________ Date: ____________



© 2002 American Dental Association
All Rights Reserved

Reproduction and use of this form by dentists and their staff is permitted.  Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.

This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).

 

Click Here to Close Window after printing is complete.