Patient Information

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    Welcome to Desert Sky Family Dental. So we are able to provide the safest, comprehensive dental care possible, we ask that you complete this detailed medical form. Please feel free to ask questions about any item that you are not familiar with.

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  • Dental Insurance Information

  • Practice Policies








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  • Notice of Privacy Practices

  •     Health Insurance Portability & Accountability Act of 1996

    Federal & state laws require Desert Sky Family Dental, LLC (DSFD) to maintain the privacy of all patient healthcare information.  Furthermore, we are required by law to provide all parents or legal guardians with this notice reviewing our privacy practices, our legal obligations and your rights in regards to your child’s healthcare information.  DSFD must follow the privacy practices as described within this notice while this policy is in effect.  This notice takes effect on February 1, 2008 and will remain in effect until replaced, amended or eliminated.

    DSFD reserves the right to change these privacy practices and the terms of this notice at any time, provided such applicable laws permit such changes.  We reserve the right to make any needed changes to our privacy practices and these new terms will be effective for all health information that we maintain, including health information we create or receive before such made changes.  Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request.

    Parents or legal guardians may request a copy of this notice, at any time.  For additional information about our privacy practices or to review our company’s Health Insurance Portability & Accountability Act (HIPAA) Manual, please contact us at any time.

    USES & DISCLOSURES OF HEALTHCARE INFORMATION

    Desert Sky Family Dental, LLC (DSFD) will use and disclose patient healthcare information during your  treatment, while obtaining payment from insurance companies and during general healthcare operations.  For example:

    Treatment. DSFD may use your health information during direct treatment or by disclosing such information to other dentists, physicians or healthcare providers who may provide specialized treatment for you

    Payment. We may also use and disclose your health information to obtain payment for services rendered.  We may disclose your healthcare information to another healthcare provider or entity that is also subject to these same federal & state Privacy Rules & Regulations for payment activities.

    Healthcare Operations. We may use and disclose your healthcare information during our routine healthcare operations.  Healthcare operations may include quality assessments and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. We may disclose your healthcare information to another healthcare provider or organization that is subject to the same federal & state Privacy Rules & Regulations and that has a relationship with you during the support of healthcare operations.  We may disclose your information to help such organizations conduct quality assessment and improvement activities, review the competence or qualifications of healthcare professionals or detect or prevent healthcare fraud and abuse.

    On Your Authorization. You may give DSFD written authorization to use your healthcare information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing, at any time.  Your revocation will not affect any uses or disclosures permitted by your authorization while it was in effect.  Unless you give us a written authorization, we cannot use or disclose your healthcare information for any reason except those described within this notice.

    To Your Family & Friends.  We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for previously performed healthcare services.  Before we disclose your health information to these people, we will provide you with an opportunity to object to our use or disclosure.  If you are not present, or in the event you are incapacitated and cannot make a decision for yourself, or in the event of an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be appropriate and in your best interest.  We will use our professional judgment and our experience with common practices to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical/dental supplies, radiographs, or other similar forms including health information.  We may also use or disclose information about you to notify or assist in notifying a person involved in his/her care.

    Appointment Reminders. DSFD may use or disclose your healthcare information to provide you and your family with appointment reminders (such as telephone calls, voice messages, postcards, or letters).

    Disaster Relief.  We may use or disclose your healthcare information to a public or private entity authorized by law or by its charter to assist in federal or state disaster relief efforts.

    Public Benefit. We may disclose your medical/dental information, as authorized by federal or state law for the following purposes deemed to be in the public’s best interest or benefit:

    • As required by law.
    • For public health activities, including disease and vital statistic reporting, reporting child abuse or neglect, FDA oversight, and to employers regarding work-related illness or injury.
    • To health oversight agencies.
    • In response to court and administrative orders and other lawful processes.
    • To law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious   deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person.
    • To coroners, medical examiners and funeral directors.
    • To an organ procurement organization.
    • To avert a serious threat to health or safety.
    • In connection with certain research activities.
    • To the military and to federal officials for lawful intelligence, counterintelligence and national security activities.
    • To correctional institutions regarding inmates.
    • As authorized by state worker’s compensation laws.

    PARENT/LEGAL GUARDIAN RIGHTS

    Access. You have the right to look at or get a copy of your health information, with limited expectations.  You may request that we provide a copy in a format other than photocopies.  We will use the format you request, unless we cannot practically do so.  You must make all requests in writing to obtain access to your child’s healthcare information.  You may request access by sending us a letter. If you request a copy, we will charge you a reasonable fee, which may include labor, copying costs and postage.  If you request an alternative format, we will charge a cost-based fee for providing your  health information in that format.  If you prefer, we may, but are not required to, prepare a summary or an explanation of your health information for a fee.

    Disclosure Accounting. You have the right to receive a list of instances in which DSFD or any of our business associates disclosed your health information over the past year (but not prior to February 1, 2008). That list will not include disclosures for treatment, payment, healthcare operations, as authorized by you, and for certain activities.  If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

    Restriction. You have the right to request that we place additional restrictions on the use or disclosure of your healthcare information.  We are not required to agree with such additional restrictions, but if we do, we will abide by our agreement (except in the event of an emergency). Any agreement we may make to a request for additional restrictions must be in writing and signed by our privacy officer.  Your request is not binding unless our agreement is in writing.

    Alternative Communication.  You have the right to request that we communicate with you about your health information by an alternative means or at an alternative location.  You must make your request in writing.  You must specify in your request the alternative means or location and satisfactory explanation how you will handle payment under the alternative means or location you request.

    Amendment. You have the right to request that we amend your healthcare information.  Your request must be in writing and should explain why you are requesting this amendment.  We may deny your request under certain circumstances.

    QUESTIONS OR COMPLAINTS

    If you want more information regarding our office’s Privacy Practices & Regulations or have a specific question or concern, please feel free to contact us.  Furthermore, if you believe that:

    • We may have violated your privacy rights.
    • We made a decision about access to your health information incorrectly.
    • Our response to a previous request to amend or restrict the use or disclosure of your information was incorrect.
    • We should communicate with you by alternative means or at an alternative location.

    You may submit a written complaint with our privacy officer or directly to the U.S. Department of Health & Human Services.  We will provide you with these addresses to file your complaint, upon your request.  We support your right to the privacy of your child’s health information.  We will not retaliate in any way if you choose to file a complaint with us or the U.S. Department of Health & Human Services.

    I understand the contents of the previous notice concerning the privacy of my confidential healthcare information.  I do hereby provide consent for the standard use of such information and understand that these provisions prohibit Desert Sky Family Dental, LLC from selling or transferring this information to any unauthorized locations with out my prior approval.  I have reviewed this information and all questions have been answered to my satisfaction. 

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  • Sierra Sky Dental

    5259 W. Indian School Rd.
    Suite 110
    Phoenix, AZ, 85031

    (623) 849-1000

  • Desert Sky Dental

    7620 W. Thomas Rd.
    Suite 102
    Phoenix, AZ 85033

    (602) 535-2682

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