NOTICE OF PRIVACY PRACTICES
Effective Date:September 16, 2013
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 PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.
For more information about our privacy practices, to discuss questions or concerns, or to get additional copies of this notice, please contact our Privacy Officer. Katey Lopez
Title: Privacy Officer Telephone: (715) 842–3704 Fax: (715) 842-4207
Email Address: firstname.lastname@example.org
OUR LEGAL DUTY
We are required by law to protect the privacy of your protected health
information (“medical information”). We are also required to send you this notice
about our privacy practices, our legal duties, and your rights concerning your
We must follow the privacy practices that are described in this notice while it is
in effect. This notice takes effect on the date set forth at the top of this page, and
will remain in effect unless we replace it.
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 any change in our privacy practices and the new terms
of our notice applicable to all medical information we maintain, including medical
information we created or received before we made the change.
We may amend the terms of this notice at any time. If we make a material
change to our policy practices, we will provide to you the revised notice. Any
revised notice will be effective for all health information that we maintain. The
effective date of a revised notice will be noted. A copy of the current notice in
effect will be available in our facility and on our website if applicable. You may
request a copy of the current notice at any time.
We collect and maintain oral, written and electronic information to administer
our business and to provide products, services and information of importance to
our patients. We maintain physical, electronic and procedural security safeguards
in the handling and maintenance of our patients’ medical information, in
accordance with applicable state and federal standards, to protect against risks
such as loss, destruction or misuse.
USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION
Treatment: We may disclose your medical information, without your prior
approval, to another dentist, a physician or other health care provider working
in our facility or otherwise providing you treatment for the purpose of evaluating
your health, diagnosing medical conditions, and providing treatment. For example,
your health information may be disclosed to an oral surgeon to determine whether
surgical intervention is needed.
Payment: We provide dental services. Your medical information may be used
to seek payment from your insurance plan. For example, your insurance plan may
request and receive information on dates that you received services at our facility
in order to allow your employer to verify and process your insurance claim.
Health Care Operations: We may use and disclose your medical information,
without your prior approval, for health care operations. Health care operations
• healthcare quality assessment and improvement activities;
• reviewing and evaluating dental care provider performance, qualifications
and competence, health care training programs, provider accreditation,
certification, licensing and credentialing activities;
• conducting or arranging for medical reviews, audits, and legal services,
including fraud and abuse detection and prevention; and
• business planning, development, management, and general administration,
including customer service, complaint resolutions and billing, de-identifying
medical information, and creating limited data sets for health care operations,
public health activities, and research.
We may disclose your medical information to another dental or medical provider
or to your health plan subject to federal privacy protection laws, as long as the
provider or plan has or had a relationship with you and the medical information
is for that provider’s or plan’s health care quality assessment and improvement
activities, competence and qualification evaluation and review activities, or fraud
and abuse detection and prevention.
Your Authorization: You (or your legal personal representative) may give us
written authorization to use your medical information or to disclose it to anyone for
any purpose. Once you give us authorization to release your medical information,
we cannot guarantee that the person to whom the information is provided
will not disclose the information. You may take back or “revoke” your written
authorization at any time in writing, except if we have already acted based on your
authorization. Your revocation will not affect any use or disclosure permitted by
your authorization while it was in effect. Unless you give us a written authorization,
we will not use or disclose your medical information for any purpose other than
those described in this notice. We will obtain your authorization prior to using your
medical information for marketing, fundraising purposes or for commercial use.
Once authorized, you may opt out of any of these communications.
Family, Friends, and Others Involved in Your Care or Payment for Care: We
may disclose your medical information to a family member, friend or any other
person you involve in your care or payment for your health care. We will disclose
only the medical information that is relevant to the person’s involvement.
We may use or disclose your name, location, and general condition to notify,
or to assist an appropriate public or private agency to locate and notify, a person
responsible for your care in appropriate situations, such as a medical emergency
or during disaster relief efforts.
We will provide you with an opportunity to object to these disclosures, unless
you are not present or are incapacitated or it is an emergency or disaster relief
situation. In those situations, we will use our professional judgment to determine
whether disclosing your medical information is in your best interest under the
Health-Related Products and Services: We may use your medical information
to communicate with you about health-related products, benefits, services,
payment for those products and services, and treatment alternatives.
Reminders: We may use or disclose medical information to send you reminders
about your dental care, such as appointment reminders.
Plan Sponsors: If your dental insurance coverage is through an employer’s
sponsored group dental plan, we may share summary health information with the
Public Health and Benefit Activities: We may use and disclose your medical
information, without your permission, when required by law, and when authorized
by law for the following kinds of public health and public benefit activities:
• for public health, including to report disease and vital statistics, child abuse,
and adult abuse, neglect or domestic violence;
• to avert a serious and imminent threat to health or safety;
• for health care oversight, such as activities of state insurance commissioners,
licensing and peer review authorities, and fraud prevention agencies;
• for research;
• in response to court and administrative orders and other lawful process;
• to law enforcement officials with regard to crime victims and criminal
• to coroners, medical examiners, funeral directors, and organ procurement
• to the military, to federal officials for lawful intelligence, counterintelligence,
and national security activities, and to correctional institutions and law
enforcement regarding persons in lawful custody; and
• as authorized by state worker’s compensation laws.
If a use or disclosure of health information described above in this notice is
prohibited or materially limited by other laws that apply to us, it is our intent to
meet the requirements of the more stringent law.
Business Associates: We may disclose your medical information to our
business associates that perform functions on our behalf or provide us with
services if the information is necessary for such functions or services. Our
business associates are required, under contract with us, to protect the privacy of
your information and are not allowed to use or disclose any information other than
as specified in our contract.
Data Breach Notification Purposes: We may use your contact information to
provide legally-required notices of unauthorized acquisition, access, or disclosure
of your health information.
Additional Restrictions on Use and Disclosure: Certain federal and state
laws may require special privacy protections that restrict the use and disclosure
of certain health information, including highly confidential information about you.
“Highly confidential information” may include confidential information under Federal
laws governing alcohol and drug abuse information and genetic information as
well as state laws that often protect the following types of information:
2. Mental health;
3. Genetic tests;
4. Alcohol and drug abuse;
5. Sexually transmitted diseases and reproductive health information; and
6. Child or adult abuse or neglect, including sexual assault.
Access: You have the right to examine and to receive a copy of your medical
information, with limited exceptions. We will use the format you request unless
we cannot practicably do so. You should submit your request in writing to our
We may charge you reasonable, cost-based fees for a copy of your medical
information, for mailing the copy to you, and for preparing any summary or
explanation of your medical information you request. Contact our Privacy Officer
for information about our fees.
Disclosure Accounting: You have the right to a list of instances in which we
disclose your medical information for purposes other than treatment, payment,
health care operations, as authorized by you, and for certain other activities.
You should submit your request to our Privacy Officer. We will provide you with
information about each accountable disclosure that we made during the period for
which you request the accounting, except we are not obligated to account for a
disclosure that occurred more than 6 years before the date of your request.
Amendment: You have the right to request that we amend your medical
information. You should submit your request in writing to our Privacy Officer.
We may deny your request only for certain reasons. If we deny your request, we
will provide you a written explanation. If we deny your request, you may have a
statement of your disagreement added to your medical information. If we accept
your request, we will make your amendment part of your medical information and
use reasonable efforts to inform others of the amendment who we know may
have and rely on the unamended information to your detriment, as well as persons
you want to receive the amendment.
Restriction: You have the right to request that we restrict our use or disclosure
of your medical information for treatment, payment or health care operations, or
with family, friends or others you identify. Except in limited circumstances, we
are not required to agree to your request. But if we do agree, we will abide by
our agreement, except in a medical emergency or as required or authorized by
law. You should submit your request to our Privacy Officer. Except as otherwise
required by law, we must agree to a restriction request if:
1. except as otherwise required by law, the disclosure is to a health plan for
purposes of carrying out payment or health care operations (and not for purposes
of carrying out treatment); and
2. the medical information pertains solely to a health care item or service for
which the health care provider involved has been paid out of pocket in full by the
Confidential Communication: You have the right to request that we
communicate with you about your medical information in confidence by means
or to locations that you specify. You should submit your request in writing to our
Breach Notification: You have the right to receive notice of a breach of
your unsecured medical information. Breach may be delayed or not provided
if so required by a law enforcement official. You may request that notice be
provided by electronic mail. If you are deceased and there is a breach of your
medical information, the notice will be provided to your next of kin or personal
representatives if we know the identity and address of such individual(s).
Electronic Notice: If you receive this notice on our web site or by electronic
mail (e-mail), you are entitled to receive this notice in written form. Please contact
our Privacy Officer to obtain this notice in written form.
If you are concerned that we may have violated your privacy rights, or you
disagree with a decision we made about access to your medical information,
about amending your medical information, about restricting our use or disclosure
of your medical information, or about how we communicate with you about your
medical information (including a breach notice communication), you may contact
to our Privacy Officer.
You also may submit a written complaint to the Office for Civil Rights of the
United States Department of Health and Human Services, 200 Independence
Avenue, SW, Room 509F, Washington, D.C. 20201. You may contact the Office for
Civil Rights’ Hotline at 1-800-368-1019.
We support your right to the privacy of your medical 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 Social Services.