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 Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that
requires all medical records
and other individually identifiable health information used or disclosed by us in any form, whether
electronically, on paper, or
orally, are kept properly confidential. This Act gives you, the patient, significant new rights to
understand and control how
your health information is used. HIPAA provides penalties for covered entities that misuse personal
As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy
of your health information and how we may use and disclose your health information. If you sign a
Consent Form, we may use and disclose
your medical records only for each of the following purposes: treatment, payment and healthcare
- Treatment: means providing, coordinating, or managing healthcare and related
services by one or more
An example of this would include teeth cleaning services.
Payment: means such activities as obtaining reimbursement for services, confirming
coverage, billing or collection activities,
and utilization review. An example of this would be sending a bill for your visit to your insurance
company for payment.
Healthcare operations: include the business aspects of running our practice, such
as conducting quality assessment and improvement
activities, auditing functions, cost management analysis, and customer service. An example would be
an internal quality assessment review.
We may also create and distribute de-identified health information by removing all references to
information. We may, without prior consent, use or disclose protected health information to carry out
or healthcare operations in the following circumstances:
In emergency treatment situations, if we attempt to obtain such consent as soon as reasonably
practicable after the delivery of such treatment;
- If we are required by law to treat you, and we attempt to obtain such consent but are unable to
contain such consent; or
If we attempt to obtain your consent but are unable to do so due to substantial barriers to
communicating with you, and
we determine that, in our professional judgment, your consent to receive treatment is clearly
inferred from the circumstances.
We may contact you to provide appointment reminders or information about treatment alternatives or other
benefits and services that may be of interest to you.
Any other uses and disclosures will be made only with your written authorization. You may revoke such
authorization in writing
and we are required to honor and abide by that written request, except to the extent that we have
already taken actions relying
on your authorization.
You have the following rights with respect to your protected health information, which you can exercise
by presenting a written
request to the Privacy Officer:
The right to request restrictions on certain uses and disclosures of protected health information,
including those related to disclosures to family
members, other relatives, close personal friends, or any other person identified by you. We are,
however, not required to agree to a requested
restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to
The right to reasonable requests to receive confidential communications of protected health
information from us by alternative means or at
The right to inspect and copy your protected health information.
- The right to amend your protected health information.
- The right to receive an accounting of disclosures of protected health information.
- The right to obtain a paper copy of this notice from us upon request.
We are required by law to maintain the privacy of your protected health information and to provide you
with notice of our legal
duties and privacy practices with respect to protected health information. This notice is effective as
of October 17, 2002 and we
are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve
the right to change the terms
of our Notice of Privacy Practices and to make the new notice provisions effective for all protected
health information that we
maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from
this office. You have
recourse if you feel that your privacy protections have been violated. You have the right to file a
formal, written complaint with us
at the address below, or with the Department of Health & Human Services, Office of Civil Rights, about
violations of the provisions
of this notice or the policies and procedures of our office. We will not retaliate against you for
filing a complaint.