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Download Notice of Privacy Policy

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. Additional copies and information about our privacy practices may be obtained from the HIPAA Coordinator.



The following describes how information about you may be used in this dental office:

  • Announcement: We may announce your name in the reception area when we are ready to see you.

  • Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders such as voicemail messages, email, postcards or letters.

  • 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: We may use and disclose your health information to obtain payment for services we provide to you.

  • Health Care Operations: May use and disclose your health information in connection with our health care operations. Health care operations include, but are not limited to, quality assurance, training, licensing, and certification programs.

  • Marketing: We will not use your health information for marketing purposes without your written authorization.

  • Legal Requirements: We may 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 officials when required for intelligence and national security activities. Health information for inmates in custody of law enforcement may also 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 any other person if necessary to assist with your treatment and/or payment for services. 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, general condition or death.

  • Unsecured Email: We will not send you unsecured emails pertaining to your health information without your prior authorization; you have the right to revoke the authorization at any time.

  • 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.

  • Research: Your health information may be disclosed to researchers for research purposes. In this situation, written authorization is not required as approved by an Institutional Review Board or privacy board.

  • Fundraising: We may use or disclose demographic information and dates of treatment in order to contact you for fundraising activities. If you no longer wish to receive these communications, notify us.

  • Public Health Activities: Occasionally, we may disclose medical information for public health activities. These activities 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 (only when required by law).

  • Change of Ownership: If this dental practice is sold or merged with another practice or organization, your health records will become the property of the new owner. However, you may request that copies of your health information be transferred to another dental practice.


Note: In addition to our use of your health information for treatment, payment or healthcare 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 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 health information for any reason except those described in this Notice.




  • 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 and mailing services. If you request x-rays, there will be a fee for any copies of films. You are not entitled to originals, only copies. 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.

  • 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 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 are not 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, and it must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

  • Breach Notification: In the event your unsecured protected health information is breached, we will notify you as required by law. In some situations, you may be notified by our business associates.

  • Amendment: 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. We may deny your request under certain circumstances.




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 end of this Notice. You also may submit a written complaint to the DHHS. We will provide you with the address to file your complaint with the DHHS 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 DHHS.

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