We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 7/12/21 and remains in effect until we replace it.

We reserve the right to change our privacy practices and the term of this Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request.

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.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example.  Some information, such as HIV-related information, genetic information, alcohol and /or substance abuse record, and mental health records may be entitled to special confidentiality protections under applicable state for federal law.  We will abide by these special protections as they pertain to applicable cases involving these types of records.


TREATMENT: We may use and disclose your health information for your treatment.  For example, we may disclose your health information to a specialist providing treatment to you.


PAYMENT: We may use and disclose your health information to obtain reimbursement for the treatment and services you received from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party.  For example, we may send claims to your dental health plan containing certain health information.


HEALTHCARE OPERATIONS: We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities.


INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT OF YOUR CARE:   WE may disclose you health information to you family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative.  If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your 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.


PUBLIC HEALTH ACTIVITIES:  We may disclose your health information for public health activities, including disclosures to:

_Prevent or control disease, injury or disability;

_Report child abuse or neglect

_Report reactions to medication or problems with product or devices

_Notify a person of a recall, repair, or replacement of products or devices

_Notify a person who may have been exposed to a disease or condition; or

_Notify the appropriate government authority if we believe a patient has been a victim or abuse, neglect, or domestic violence


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


SECRETARY OF HHS:  WE will disclose your health information to the Secretary of US Department of Health and Human Services when required to investigate or determine compliance with HIPAA


WORKER’S COMPENSATION:  We may disclose you PHI to extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

LAW ENFORCEMENT:  We may disclose you PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.


HEALTH OVERSIGHT ACTIVITIES: We may disclose you PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.


JUDICIAL AND ADMINISTRATIVE PROCEEDINGS:  If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order.  We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.


RESEARCH:  We may disclose you PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy or you information.


CORONERS, MEDICAL EXAMINERS, AND FUNERAL DIRECTORS:  We may release you PHI to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person or determine the cause of death.  We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.


FUNDRAISING:  We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications.


OTHER USES AND DISCLOSURES OF PHI  Your authorization is required, with a few exception, for disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI.  We will obtain your written authorization before using or disclosing you PHI for purposes other than those provided for in this Notice (or as otherwise permitted or required by law). You make revoke an authorization in writing at any time.  Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.


YOUR HEALTH INFORMATION RIGHTS: Access.  You have the right to look at or get copies of your health information, with limited exception. You must make the request in writing. You may obtain a form to request access by using the contact information listed at the beginning of this Notice. You may also request access by sending us a letter.  If you request information that we maintain on paper, we may provide photocopies.  If you request information that we maintain electronically, you have the right to an electronic copy.  We will use the form and format you request if readily producible.  Contact us using the information at the beginning of this Notice


DISCLOSURE ACCOUNTING:   With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations.  To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official.  IF you are requesting this accounting more than once in 12month period, we may charge you a reasonable, cost-based fee for responding to the additional request.


RIGHT TO REQUEST A RESTRICTION: You have the right to request additional restrictions on our use or disclosure of you PHI by submitting a written request to the Privacy Official.  Your written request must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply.  We are not required to agree to you request except in the case where the disclosure is to a health plan for purposes of caring our payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than health plan), has paid our practice in full.


ALTERNATIVE COMMUNICATION:  You have the right to request that we communicate with you about your health information by alternative means or at alternative location.  You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable request. However, if we are unable to contact you using the ways or locations you have requested we may contact you using the information we have.


AMENDMENT: You have the right to request that we amend you health information.  You request must be in writing, and must explain why the information should be amended.  We may deny your request under certain circumstances. If we agree to your request, we will amend your records and notify you of such.  If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.


RIGHT TO NOTIFICATION OF A BREACH:  You will receive notification of breaches of you unsecured protected health information as required by law.


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 e-mail


QUESTIONS AND COMPLAINTS:   If you are concerned that we may have violated your privacy right, or if 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 to alternative location, you may complain to us using the contact information listed at the beginning. You may also may submit a written complaint to the US Department of Health and Services.

Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any other requires the prior written approval of the ADA.  This material is educational only, does not constitute legal advice, and covers only federal, not state, law.