THIS 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.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that health
providers keep your medical and dental information private. The HIPAA Privacy Rule states that
health providers must also post in a clear and prominent location, and provide patients with, a
written Notice of Privacy Policy.
The privacy practices described are currently in effect. We reserve the right to change our privacy
practices, and the terms of this Notice at any time, provided such changes are permitted by law. If
changes are made, a new Notice of Privacy Policy will be displayed in our office and provided to
patients. You may request a copy of our Notice at any time. Additional information may be obtained
from the HIPAA Coordinator listed in our written HIPAA plan.
USES AND DISCLOSURES OF HEALTH INFORMATION
The following describes how information about you may be used in this dental office:
Treatment Services: We may use or disclose your health information to all of our staff members,
other dentists, your physicians, and/or other health care providers taking care of you.
Payment and Health Care Operations: We may use or disclose your health information to obtain
payment for services we provide to you, to participate in quality assurance, disease management,
training, licensing, and certification programs. Upon your written request, we will not disclose to your
health insurer any services paid by you out of pocket.
Marketing/Fundraising: We will not use your health information for marketing or fundraising
purposes without your written consent. You can opt out of receiving information about our marketing
or fundraisers. We will not sell your health information without your explicit authorization.
Appointment Reminders: We may use or disclose your health information to provide you with
appointment reminders such as voicemail messages, text messages, emails, postcards, or letters.
Legal Requirements: We may use or disclose your health information when required to do so by
law.
Abuse or Neglect: If abuse or neglect is reasonably suspected, we may use or disclose your health
information to the appropriate governmental authorities.
National Security: When required, we may disclose military personnel health information to the
Armed Forces. Information may be given to authorized federal offices when required for intelligence
and national security activities. Health information for inmates in custody of law enforcement may be
provided to correctional institutes.
Family Members, Friends, and Others Involved in Care: At your request, we may disclose your
health information to a family member or other person if necessary to assist with your treatment and/
or payment for services. Based on our judgement and as per 164.522(a) of HIPAA we may disclose
your information to these persons in the event of an emergency situation. We also may make
information available so that another person may pick up filled prescriptions, medical supplies,
records, or x-rays for you. Your information may be disclosed to assist in notifying a family member,
caregiver, or personal representative of your location, condition, or death.
Business Associates: Some services in our organization are provided through contacts with
business associates. Examples include practice management software representatives, accountants,
answering service personnel, etc. When these services are contracted, we may disclose your health
information to our business associates so that they can perform the job we have asked them to do
and bill you or your third-party payer for services rendered. All of our business associates are
required to safeguard your information and to follow HIPAA Privacy Rules.
Workers’ Compensation: We may release medical information about you for workers’ compensation
or similar programs. These programs provide benefits for work-related injuries or illnesses.
Research: We may use or disclose medical information to researchers when an institution’s review
board or special privacy board has reviewed the proposed study and established protocols to ensure
the privacy of the health information used in their research and determined that the researcher does
not need to obtain your authorization prior to using your medical information for research purposes.
Public Health Activities: We may use or disclose your health information for public health activities,
to include the following: to prevent or control disease, injury, or disability; to report reactions with
medications or problems with products; to notify people of recalls of products they may be using; to
notify a person who may have been exposed to a disease or who may be at risk for contracting or
spreading a disease or condition; to notify the proper government authority if we believe a patient has
been the victim of abuse, neglect, or domestic violence (when required by law).
Other Authorizations: In addition to our use of your health information for treatment, payment, or
health care operations, you may give us written authorization to use your health information or to
disclose it to anyone for any purpose. If you give us authorization, you may revoke it at any time.
Your revocation will not affect any use or disclosures permitted by your authorization while it was in
effect. Unless you give us a written authorization, we cannot use or disclose your health information
for any reason except those described in this Notice.
Breach Notification: We will notify you any time your PHI may have been compromised through
unauthorized acquisition, use or disclosure.
Substance Use Disorder (SUD) Records: The confidentiality of substance use disorder patient
records is protected by strict federal law and regulations (42 CFR Part 2). Generally, we may not
disclose any information identifying a patient as having a substance use disorder unless: the patient
consents in writing; the disclosure is allowed by a court order; or the disclosure is made to medical
personnel in a medical emergency. Information related to substance use disorder treatment cannot
be used to criminally investigate or prosecute a patient.
Reproductive Health Care Privacy: We recognize that information regarding reproductive health
care is highly sensitive. We will not use or disclose your protected health information to conduct a
criminal, civil, or administrative investigation into, or impose liability for, the mere act of seeking,
obtaining, providing, or facilitating lawful reproductive health care.
PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited
exceptions. You may request that we provide copies in a format other than photocopies. We will use
the format you request unless we cannot practicably do so. You must make a request in writing to
obtain access to your health information. We will charge you a reasonable cost-based fee for
expenses such as copies. If you request x-rays, there will be a fee for any copies of films. You are not
entitled to originals, only copies. Postage will be added if copies are to be mailed. If you prefer, we
will prepare a summary or an explanation of your health information for a fee. Details of all fees are
available from the HIPAA Coordinator.
Accounting of Disclosures: You have the right to receive a list of instances in which we or our
business associates disclosed your health information for purposes, other than treatment, payment,
healthcare operations and certain other activities, for the last 6 years. 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 our use or
disclosure of your health information. We will keep your information confidential from your health
plans if you pay cash, at your request. In some instances, we may not be required to agree to these
additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about
your health information by alternative means or to alternative locations. (You must make your request
in writing.) Your request must specify the alternative means or location, and provide satisfactory
explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. (Your request
must be in writing, and must explain the reason for the amendment.) We may deny your request
under certain circumstances.
QUESTIONS AND COMPLAINTS
If you want more information about our Privacy Policy or have questions or concerns, please contact
us. If you have concerns relating to a perceived violation of your privacy rights, to access to your
health information, to amending or restricting the use or disclosure of your health information, or to
requesting alternative means of communication, you may contact us using the contact information
listed at the top of this Notice. You also may submit a written complaint to the Department of Health
and Human Services (HHS). We will provide you with the HHS address 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 HHS.
