Notice of Privacy Practices

Your Information. Your Rights. Our Responsibilities.

This notice explains how your health information may be used and disclosed, and how you can access it. Please review it carefully.

Protected Health Information (PHI):
PHI is any information that can identify you, such as your demographics, and relates to your past, present, or future health, dental care, or payment for services.

Your Rights Regarding PHI

You have the right to:

• Access your medical record – You may ask to see or get a paper or electronic copy of your dental/medical record. We will provide it within 30 days of your request. A reasonable, cost-based fee may apply.

• Request corrections – If you believe your record is incorrect or incomplete, you may ask us to correct it. We may deny your request, but will provide a written explanation within 60 days.

• Request confidential communication – You can ask us to contact you by specific means (for example, your home phone, office phone, or alternate address). We will honor all reasonable requests.

• Limit what we use or share – You may ask us not to use or disclose certain information for treatment, payment, or operations. While we are not required to agree, if you pay for a service in full out-of-pocket, we will not share that information with your health plan unless required by law.

• Get a list of disclosures – You may request a record of who we’ve shared your health information with (other than for treatment, payment, and operations) going back six years. The first list each year is free; additional requests may involve a reasonable fee.

• Receive a copy of this notice – You can request a paper copy of this notice at any time, even if you agreed to receive it electronically.

• Designate a representative – If you have appointed a medical power of attorney or legal guardian, that person may act for you and exercise your rights.

• File a complaint – If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you may decide how we share it. You have the right to tell us whether we may:

• Share information with family members or others involved in your care.

• Share information during emergencies when you are unable to state your preferences.

If you cannot express your choice (for example, if you are unconscious), we may share your information if we believe it is in your best interest or necessary to reduce a serious and imminent threat to health or safety.

How We Use and Disclose Information

We typically use or share your PHI in the following ways:

• Treatment – To provide and coordinate your care.
  Example: We may share information with a specialist or laboratory at your dentist’s request, or disclose information to another provider involved in your care as necessary. We may, as necessary, disclose your protected health information to another physician or healthcare provider (including, for example, a specialist or laboratory) who, at the request of your treating physician, becomes involved in your care by assisting with your diagnosis or treatment.

• Payment – To bill and collect payment for your services.
  Example: We may share details with your health plan to confirm coverage or obtain pre-authorization for a procedure.

• Health care operations – To run our practice and improve care.
  Example: We may use your information for quality reviews, staff training, licensing, or to remind you of an appointment.

We may also use or share your PHI in these situations, these examples are not meant to be exhaustive, but to describe the types of uses and disclosures that maybe made by our office

• With business associates – Such as billing companies or transcription services. Business associates are required by contract to protect your information.

• Marketing and communication – We may provide information about treatment alternatives, services, or health-related benefits. You can opt out of receiving marketing materials at any time.

• Research – In limited circumstances, we may use or share PHI for research.

• Public health and safety – To report abuse, neglect, domestic violence, or prevent/lessen a serious threat to health or safety.

• Oversight activities – For audits, investigations, or inspections by health oversight agencies.

• Law enforcement and legal requirements – In response to court orders, subpoenas, or as otherwise required by law.

• Special government functions – For military, national security, or protective services.

• Workers’ compensation – As authorized by applicable laws.

• After death – With coroners, medical examiners, funeral directors, or organ donation organizations.

• FDA and product safety – To report adverse events, recalls, or product monitoring as required by the Food and Drug Administration.

With your written authorization: Any other use or disclosure of PHI not described above will be made only with your written consent. You may revoke this authorization at any time in writing.

Our Responsibilities

We are required by law to:

• Maintain the privacy and security of your PHI.

• Notify you promptly if a breach occurs that may compromise your information.

• Follow the duties and practices described in this notice.

• Not use or share your information other than as described here unless you give us written permission. If you provide authorization, you may revoke it at any time in writing.

Changes to This Notice

We may change the terms of this notice at any time, and the changes will apply to all information we maintain, including information gathered before the change. The updated notice will be posted in our office and on our website. You may request a paper copy at any time.

More Information:
For additional details about your rights under HIPAA, visit: www.hhs.gov/hipaa/for-individuals.