The Privacy of Your Health Information is Important to Us

New and existing patients will be asked to provide us with medical and personal information. Our office takes reasonable precautions to protect the privacy of your health information, and although to date we know of no violations of patient privacy, we cannot guarantee that, accidentally or intentionally, your privacy will not be compromised. 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 effective for all health information we maintain, including health information we created or received before making the changes. Before we make a significant change in our privacy practices, we will change this Notice and provide the new Notice at our physical practice location, and we will distribute it upon request.

Uses and Disclosures of Health Information

We use and disclose health information about you without authorization for the following purposes:

Your Authorization:

In addition to our use of your health information for the following purposes, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you so authorize us, you may revoke your authorization 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 health information for any reason except those described in this Notice.

Treatment:

We may use or disclose your health information for your treatment. For example, we may disclose your health information to other dental or medical professionals providing treatment to you.

Payment:

We may disclose your personal health information to bill and collect payment for the services we provide to you. We may send a bill to you or a third-party payor for services we have rendered. The bill may contain information that identifies you, your diagnosis and procedures, and the supplies used. We may need to disclose this information to insurance companies to establish insurance eligibility benefits for you. We may also provide your personal health information to our business associates, such as billing companies, claims processing companies and others that process our health care claims. For example, we may send claims to your dental health plan containing certain health information.

Healthcare Operations:

We may disclose your personal health information in connection with our health care operations. Health care operations include staff education, fraud prevention, quality assessment activities and other business operations. We may also provide your personal health information to accountants, attorneys, consultants, and others to make sure we comply with the laws that govern us. For example, healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Consent to Audio Recording:

An audio recording may be taken of my dental exam, and/or of your interactions with our office’s front desk staff for quality improvement purposes only. Such an audio recording will be taken by the dentist or an audiographer approved by the dentist. Although recording will not be part of the patient chart, we will treat the recordings confidentially, just as we do all your health information.

Emergency Treatment:

We may disclose your personal health information if you require emergency treatment or cannot communicate with us.

To You or Your Personal Representative:

We will disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to your personal representative, but only if you agree that we may do so.

Persons Involved in Care:

We may use or disclose 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 before using or disclosing your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your absence or incapacity or in emergency circumstances, we will use our professional judgment to disclose only that health information 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 about your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Disaster Relief:

We may use or disclose your health information to assist in disaster relief efforts.

Required by Law:

We may use or disclose your health information when we are required to do so by law. We may disclose health information about a decedent as authorized or required by law.

Public Health and Public Benefit:

We may use or disclose your health information to report abuse, neglect, or domestic violence; to report disease, injury, and vital statistics; to report certain information to the Food and Drug Administration (FDA); to alert someone who may be at risk of contracting or spreading a disease; for health oversight activities; for certain judicial and administrative proceedings; for certain law enforcement purposes; to avert a serious threat to health or safety; and to comply with workers’ compensation or similar programs.

Health Oversight Activities:

We may disclose your personal health information to a health oversight agency for activities authorized by law. These activities include audits; civil, administrative, or criminal investigations or proceedings; inspections; licensure or disciplinary actions; or other activities necessary to oversee the health care system, government programs, and compliance with civil rights laws.

National Security:

Under certain circumstances, we may disclose to military authorities the health information of Armed Forces personnel. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. Under certain circumstances, we may disclose to correctional institutions or law enforcement officials having lawful custody the protected health information of an inmate or patient.

Marketing Health-Related Services:

We will not use your health information for marketing communications without your written authorization.

Appointment Reminders:

We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, text messages, postcards or letters).

Patient Rights

You may request a copy of this Notice at any time. For more information about our privacy practices or additional copies of this Notice, please contact us using the information listed at the end of this Notice.

Access:

You have the right to look at or get copies of your health information, with limited exceptions. You must make a written request to the address listed at the end of this Notice to access your information. In certain circumstances, we may deny your request to access your personal health information. We will charge you a reasonable cost-based fee for the cost of providing you your information. The cost shall be $10 per half-hour, charged in half hour increments, for staff time to copy your health information, and postage if you want the copies mailed to you.

Disclosure Accounting:

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 six years, but not before April 14, 2003. 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. In most cases, we are not required to agree to these additional restrictions. Still, if we do, we will abide by our agreement (except in certain circumstances where disclosure is required or permitted, such as an emergency, for public health activities, or when disclosure is required by law). We will comply with a request to restrict the disclosure of protected health information to a health plan for purposes of carrying out payment or health care operations (as defined by HIPAA) if the protected health information pertains solely to a health care item or service for which you have paid us out-of-pocket in full.

Alternative Communication:

You have the right to request that we communicate with you about your health information, including payment information, by alternative means or at alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location and provide a satisfactory explanation of how payments will be handled under the alternative means or location you request.

Amendment:

For as long as we maintain your medical record, you have the right to request that we amend your personal health information if you believe it is incorrect or incomplete. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

Electronic Notice:

You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically on our website or by electronic mail (e-mail).

Right to Notice of Breach:

You have the right to be notified if one of our business associates or we become aware of a breach of your personal health information.

Questions and Complaints

If we do not exceed your expectations, please tell us why, and how we can improve. 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.