Your Information. Your Rights. Our Responsibilities.

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.

Your Rights
You have the right to:

  • Get a copy of your paper or electronic medical record
  • Correct your paper or electronic medical record
  • Request confidential communication
  • Ask us to limit the information we share
  • Get a list of those with whom we’ve shared your information
  • Get a copy of this privacy notice
  • Choose someone to act for you
  • File a complaint if you believe your privacy rights have been violated

Your Choices
You have some choices in the way that we use and share information as we:

  • Tell family and friends about your condition
  • Provide disaster relief
  • Include you in a hospital directory
  • Provide mental health care
  • Market our services and sell your information
  • Raise funds

Our Uses and Disclosures
We may use and share your information as we:

  • Treat you – for example, we may discuss your treatment with your dentist
  • Run our organization
  • Bill for your services – for example, we may share your health information with your insurance company.
  • Help with public health and safety issues
  • Do research
  • Comply with the law
  • Respond to organ and tissue donation requests
  • Work with a medical examiner or funeral director
  • Address workers’ compensation, law enforcement, and other government requests
  • Respond to lawsuits and legal actions

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
  • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
  • We may say "no" to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • We will say "yes" to all reasonable requests.

Ask us to limit what we use or share

  • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, costbased fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

  • You can complain if you feel we have violated your rights by contacting us using the information on page 1.
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
  • We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation
  • Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

  • Marketing purposes
  • Sale of your information

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see:

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Email Policy

When we send you an email, or you send us an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet. In addition, once the email is received by you, someone may be able to access your email account and read it. An example of this may be a friend or spouse that has access to your email account.

Email is a very popular and convenient way to communicate for a lot of people, so in their latest modification to the HIPAA act, the federal government provided guidance on email and HIPAA.

The information is available in a pdf (page 5634) on the U.S. Department of Health and Human Services website ‐‐2013‐01‐25/pdf/2013‐01073.pdf

The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email.

Email is defined as messages distributed by electronic means from one computer user to one or more recipients via a network. This may include, but not be limited to, traditional Google, Yahoo type services, Text messaging, Online chats and Facebook messages.

Cloud Storage of Patient Health Information (PHI):

Sky Ortho uses cloud storage to maintain certain PHI. This may include but not be limited to, Google Drive, Dropbox and other cloud based platforms.

Acknowledgement of Receipt of Privacy Policies and Authorization to Disclose Health Information

* First Name of Patient:
* Last Name of Patient:
* Date of Birth:
Social Security #:
THE FOLLOWING SECTION IS OPTIONAL – Only fill this out if there is someone else you want to allow us to share your health information with. Often patients want Grandparents, Friends or some other person or organization to have access to their health information. If this is the case, fill out the details in this section. If this does not apply to you, Leave this section blank and SKIP ahead to "Acknowledgements". I authorize SKY ORTHO to use or disclose the following health information.

I authorize SKY ORTHO to use or disclose the following health information.

Treatment or condition to be disclosed:
Period of which health information can be disclosed:     to  

SKY ORTHO may disclose this health information to the following recipient(s).

Persons other than adult completing the form allowed to pick up or drop off child. Also, anyone allowed to know information regarding treatment: other parent, spouse etc.


Including but not limited to other parents, relatives, spouse, significant other, etc.

The purpose of this authorization is (check all that apply):
This authorization ends:


I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.

I understand that uses and disclosures already made based upon my original permission cannot be taken back.

I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.

I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.

I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.

Be advised, if you select "NO" and we later receive an email from you, we will assume you are now consenting to the use of email.

Adult Patient

Minor Patient

If the patient is a minor or unable to sign please complete the following:

Media Release Form

I grant permission to Sky Ortho to use my image (photographs and/or video) for use in Sky Ortho publications including videos, email blasts, recruiting brochures, newsletters, and magazines and to use my image in electronic versions of the same publications or on the Sky Ortho website or other electronic forms of media. I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensations arising from or related to the use of the image.

Please check the paragraph below which is applicable to your present situation: