The RDG HIPAA forms are available in Adobe Acrobat .pdf format.  In order to view and print these forms, you will need to have the Adobe Acrobat Reader installed on your computer.

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• Notice of Privacy Practices Form
  This form, Notice of Privacy Practices, presents the information that federal law requires us to give our patients regarding our privacy practices.  
• Acknowledgement of Receipt of Notice of Privacy Practices Form
  This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement.  
  

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:  HIPAA Privacy Officer
Telephone:  (262) 637-9371
Fax:  (262) 637-3071
E-mail:  HIPAAPrivacyOfficer@RacineDentalGroup.com
Address:  Racine Dental Group, S.C., 1320 S. Green Bay Rd., Racine, WI  53406-4495