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.
THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your medical information, which is protected health information (PHI). We are also
required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy
practices that are described in this Notice while it is in effect. This Notice takes effect 9/23/13 and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the
right to make the changes in our privacy practices, and the new terms of our Notice of Privacy Practices shall be effective for all protected health information that we
maintain, including PHI which we created or received before we made the changes. Whenever we make material changes to this Notice, we will provide you with
access to the revised Notice upon your next visit to this office. You will be asked to sign a new Acknowledgement of your receipt of the Notice at that time.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the
information listed at the end of this Notice.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
We may use and disclose protected health information about you for treatment, payment, and healthcare operations without your authorization. For example:
Treatment: We may use or disclose your protected health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your protected health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your protected health information in connection with our healthcare operations. Healthcare operations
include, but are not limited to, quality assessment and improvement activities, reviews of competence or qualifications of healthcare professionals, practitioner
and provider performance evaluations, conducting training programs, and compliance, accreditation, certification, licensing and credentialing activities.
Your Authorization: In addition to our use of your protected health information for treatment, payment or healthcare operations, you may give us written authorization
to use your protected health 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 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 protected health information for any reason except those described in this Notice. A written authorization from you is required for any disclosures that
constitute a sale of your protected health information.
Disclosure To Your Family and Friends: We must disclose your protected health information to you, as described in the Patient Rights section of this Notice. We
may disclose your protected health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your
healthcare, but only if you authorize us to do so.
Persons Involved In Care: We may use or disclose protected health information to notify, or assist in the notification of (including identifying or locating) a family
member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use
of disclosure of your protected heath information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or
emergency circumstances, we will disclose protected health information based on a determination using our professional judgment disclosing only protected health
information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common
practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of
protected health information.
Marketing Health-Related Services: We will not use your protected health information for marketing communications without your written authorization.
Required By Law: We may use or disclose your protected health information when we are required to do so by law.
Abuse or Neglect: We may disclose your protected health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse,
neglect, or domestic violence or the possible victim of other crimes. We may disclose your protected health information to the extent necessary to avert a serious threat
to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the protected health information of Armed Forces personnel under certain circumstances. We may disclose
to authorized federal officials, protected health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose
to correctional institutions or law enforcement official having lawful custody of protected heath information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your protected health information to provide you with appointment reminders (including, but not limited to
voicemail messages, postcards, text messages or letters).
Access: You have the right to look at or get copies of your protected health information, with limited exceptions. You may request that we provide you copies in a
format other than photocopies, including electronic copies of any information that is held electronically. 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 protected health information listed at the end of this Notice. We will charge you a
reasonable cost- based fee for expenses such as copies, staff time, and postage. You may also request access by sending us a letter to the address at the end of this
Notice. If you request an alternative format, we will charge a cost-based fee for providing your protected health information in that format. If you prefer, we will prepare
a summary or an explanation of your protected health information for a fee.) We will send PHI in an unencrypted email only at your request after we advise you of the
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your protected health information for
purposes, other than treatment, payment, healthcare operations and certain other activities, for the past 6 years. If you request this accounting information more than once
in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Breach Notification: You have a right to be notified in the event of a breach of the privacy or security of your protected health information.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your protected health information. However, we are not
required to agree to these additional restrictions. We must abide by any request to restrict disclosure of your protected health information to your health plan if the
disclosure is for payment or health care operations and pertains to an item or service for which you paid for in full on your own, without submission of a claim for
payment to the health plan.
Alternative Communications: You have the right to request that we communicate with you about your protected 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.
Fundraising: In the event we contact you for any fundraising purpose, you have the right to “opt out” and remove yourself from receiving any such communication.
Amendment: You have the right to request that we amend your protected health information. (Your request must be in writing, and it must explain why the information
should be amended.) We may deny your request if appropriate, based upon the circumstances as permitted by law.
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 protected health information or in
response to a request you made to amend or restrict the use or disclosure of your protected 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 top 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
We support your right to the privacy of your protected 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: 200 Independence Ave SW, Room 309F HHH Bldg, Washington, DC, 20201.
If you wish to file a complaint, you may contact the Dental Center at the address and telephone number provided by them.
(Orig. date 4/1/2003; Revised 3/10/15)