For Our Patients
Fillable Forms for Patients
At Financial District Dental Care, Dr. Hahn and his team recognize that your time is valuable. In order to keep your appointment running on schedule, we ask that you fill out the forms below. Simply hit the "submit" button and they will be sent to our email. The other forms are provided for your personal reference.
Other Information for Your Reference
Our Payment and Privacy Policies can be seen here. Feel free to call our office if you have any questions.
Notice of Privacy Practices
The privacy of your health is very important to us. The following notice describes how health information about you may be used and disclosed, and how you can get access to this information. Please review it carefully. Our office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment and applying for future care or treatment. It also includes billing documents for those services.
The health and billing records we maintain are the physical property of Raymond C. Hahn, DDS, Inc.. You have the following rights with respect to your Protected Health Information:
- Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. Although not required by law, we will comply with any request.
- Obtain a paper copy of this Notice of Privacy practices for Protected Health Information (“Notice”) by making a request at our office.
- Right to inspect and copy your health record and billing record. You may exercise this right by delivering the request in writing to our office using the form we provide you upon request. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practically do so. If you request copies, we may charge a small fee. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format.
- Right to appeal a denial of access to your protected health information, except in certain circumstances.
- You have the right to request that we amend your health information. (Your request must be in writing and it must explain why the information should be amended.) Raymond C. Hahn, DDS, Inc. is not required to make such amendments. You may file a statement of disagreement if your amendment is denied and require that the request for amendment and any denial be attached in all future disclosures of your protected health information.
- Right to receive an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office using the form we provide to you upon request. An accounting will not include internal uses of information for treatment, payment or operations, disclosures made to you or made at your request or disclosures made to family members or friends in the course of providing care.
- Right to confidential communication by requesting that communication of your health information be made by alternative mean or at an alternative location by delivering the request in writing to our office using the form we provide you upon request. If you want to exercise any of the above rights, please contact us at Raymond C. Hahn, DDS, Inc., 133 Kearny St. Ste. 204, San Francisco, CA 94108 in person or in writing.
Our office is required to...
- Maintain privacy of your health information as required by the Health Insurance Portability and Accountability Act of 1996 (HIPPA).
- Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you.
- Abide by the terms of this notice.
- Accommodate your reasonable requests regarding methods to communicate health information with you.
- Accommodate your request for an accounting of disclosures.
We reserve the right to amend, change or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend this notice. You are entitled to receive a revised copy of the notice by calling and requesting a copy of our “notice”, by visiting our office and picking up a copy or by downloading the revised copy from our website at www.financialdistrictdental.com.
If you have questions, would like additional information or would like to report a problem regarding the handling of your information, you may contact us at Raymond C. Hahn, DDS, Inc., 133 Kearny St. Ste. 204, San Francisco, CA 94108. Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to us. You may also submit a written complaint to the U.S. Department of Health and Human Services, 200 Independence Ave. SW, Washington, DC 20201. We cannot and will not require you to waive the right to file a complaint with the Secretary of Health and Human Services as a condition of receiving treatment from this office. We cannot and will not retaliate against you for filing a complaint with the Secretary of Health and Human Services.
Dr. Hahn has provided the following after-care information for your continued well being. Please read and download any category that applies to your care.