385 Douglas Ave Suite 2450, Altamonte Springs FL 32714
Plaza North Dentistry



To ensure that a Notice of Privacy Practices is provided to, and acknowledged by, each patient or his/her personal representative of our Practice.


Our policy is to provide a Notice of Privacy Practices (“Notice”) to each patient of our Practice, and make a good faith effort to obtain a signed Acknowledgement of Receipt of Notice of Privacy Practices (“Acknowledgement”) from the Patient.
The Notice shall include all elements and statements that are required by law. The Notice shall inform our patients of:
  • Uses and disclosures of Protected Health Information (“PHI”) that may be made by the Facility;
  • The patient’s rights with respect to his PHI; and
  • The Facility’s legal duties with respect to such PHI.
For your convenience, you can download and print our Notice of Privacy Practice form from home. If you don't have Adobe Acrobat, you can download it for free by clicking on the icon below. Please remember to bring the completed form to your first appointment. If you have any trouble, call our office, and we will gladly send or fax the form to you.

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  1. The Notice and Acknowledgement forms will be included in the standard patient paperwork.
  2. The Practices’ Staff will provide the Notice to the patients at the time of admission.Note: In the case of an emergency treatment situation, the Facility will provide the Notice to the patient as soon as reasonably practicable after the emergency treatment situation.
  3. Our offices’ Staff will make a good faith effort to obtain the patient’s signature on the Acknowledgement at the time the Notice is provided. The Notice and signed Acknowledgement will be kept in the patient’s Business Office File.
  4. If the patient refuses or is otherwise unable to sign the Acknowledgement, the Office Staff will document, on the Acknowledgement form, what actions were taken to obtain the resident’s signature on the Acknowledgement and the reason(s) why a signed
    Acknowledgement was not obtained. This document will then be placed in the Patient’s Business Office File.
  5. The Facility will provide a copy of the written Notice to patients and to other persons upon request.
  6. The Facility will post a copy of the Notice in a clear and prominent location such as the entrance lobby or similar location.
  7. A current version of the Notice will be maintained on the Facility’s website.
  8. Whenever the Notice is revised, the Facility Privacy Official will assure that:
    1. The revised Notice is made available upon request on or after the effective date of the revision; and
    2. The revised Notice is posted in a clear and prominent location.
  9. Material changes shall not be implemented prior to the effective date of the revised Notice.
  10. A copy of each Notice issued by the Facility will be maintained for at least six years from the date it was last in effect.
  11. Any member of the workforce who has knowledge of a violation or potential violation of this Policy must make a report directly to the Privacy Official. (See the Policy “Sanctions.”)