YOUR INFORMATION. YOUR RIGHTS. OUR RESPONSIBILITIES.

This Notice describes how we may use and disclose your health information, and how you can access this information. We are required by law to maintain the privacy of your protected health information (PHI), provide you with this Notice, and follow its terms.

HOW WE MAY USE AND DISCLOSE YOUR INFORMATION

Treatment: We may use or share your information to – provide, coordinate, or manage your dental care, including consultations, referrals, prescriptions, and obtaining records from other providers.

Payment: We may use or share your information to verify insurance, submit claims, obtain payment, or manage billing and collections.

Your Right to Restrict Disclosure to Health Plans
If you pay for a service in full and out of pocket, you may request that we not disclose that information to your health plan. We must honor this request unless disclosure is required by law.

Health Care Operations: We may use or share your information for activities necessary to run our practice, such as quality improvement, staff training, accreditation, audits, and administrative functions.

We may share information with “business associates” who assist us. They are required by law to protect your information.

OTHER USES AND DISCLOSURES PERMITTED BY LAW

We may use or disclose your information without your written permission in certain situations, including:

  • Public health reporting
  • Reporting abuse, neglect, or domestic violence
  • Health oversight activities
  • Judicial or administrative proceedings
  • Law enforcement purposes
  • Coroners, medical examiners, and funeral directors
  • Organ or tissue donation
  • Research under strict oversight
  • To prevent or reduce a serious threat to health or safety
  • Specialized government functions
  • Workers’ compensation claims

Unless you object, we may share relevant information with family or friends involved in your care.

USES AND DISCLOSURES THAT REQUIRE YOUR WRITTEN AUTHORIZATION

We will obtain your written authorization before using or disclosing your information for:

  • Marketing
  • Sale of your health information
  • Most uses of psychotherapy notes (if applicable)
  • Any use or disclosure not described in this Notice

You may revoke an authorization at any time in writing.

BREACH NOTIFICATION

We will notify you promptly if a breach occurs that may have compromised the privacy or security of your unsecured health information, including information protected under 42 CFR Part 2.

SPECIAL PROTECTIONS FOR REPRODUCTIVE HEALTH INFORMATION

We will not disclose information related to lawful reproductive health care for the purpose of:

  • Investigating
  • Imposing liability
  • Identifying individuals who sought or obtained such care

Reproductive health care includes, but is not limited to:

  • Contraception
  • Pregnancy care
  • Fertility services
  • Miscarriage management
  • Abortion services where lawful
  • Treatment for pregnancy-related conditions

We will only disclose reproductive health information:

  • With your valid HIPAA-compliant authorization
  • When required by law
  • When necessary to prevent a serious and imminent threat

Attestation Requirement
Before disclosing reproductive health information for certain non-routine purposes, we must obtain a signed attestation from the requesting party confirming the request is not for prohibited purposes.

You may request a copy of any attestation obtained.

SPECIAL PROTECTIONS FOR SUBSTANCE USE DISORDER (SUD) INFORMATION
(42 CFR Part 2 — Updated 2024–2026)

If we maintain records related to substance use disorder diagnosis, treatment, or referral, these records are protected by federal confidentiality rules. We will not disclose SUD information without your written consent, except as permitted by law.

You have the right to:

  • Request an accounting of disclosures of your SUD information
  • Revoke your consent at any time
  • Receive breach notifications involving SUD information

Even if our practice does not provide SUD treatment, we comply with all applicable Part 2 requirements.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

1. Right to Access
You may request to view or obtain a copy of your health information, including electronic copies.
We will provide access within 30 days, with one 30-day extension if needed.

2. Right to Request Restrictions
You may request restrictions on how we use or disclose your information.
We are not required to agree, except for the self-pay restriction described earlier.
You may also request restrictions on disclosures related to reproductive health care.

3. Right to Request Confidential Communications
You may request that we contact you in a specific way (e.g., at work, by mail, via email).
We will accommodate reasonable requests.

4. Right to Amend
If you believe your information is incorrect or incomplete, you may request an amendment.

5. Right to an Accounting of Disclosures
You may request a list of disclosures made in the past six years, excluding those for treatment, payment, and operations. You may also request an accounting of disclosures related to:

  • Reproductive health information
  • SUD information

6. Right to a Paper Copy of This Notice
You may request a paper copy at any time.

PATIENT PORTAL & ELECTRONIC COMMUNICATIONS

If our practice offers a patient portal, you may be able to:

  • View your records
  • Request appointments
  • Send secure messages
  • Access treatment plans or billing information

If you choose to communicate with us via email or text, please be aware that these methods may carry privacy risks. You may opt out at any time.

OUR RESPONSIBILITIES

We are required to:

  • Maintain the privacy and security of your PHI
  • Notify you if a breach occurs
  • Follow the terms of this Notice
  • Provide you with a copy of this Notice upon request

We may change this Notice at any time. Updated versions will be posted in our office and on our website.

OUR NOTICE OF PRIVACY PRACTICES

By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our Web site.

COMPLAINTS

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.

FOR MORE INFORMATION

If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice.

ACKNOWLEDGMENT OF RECEIPT

You will be asked to sign a separate form acknowledging that you received this Notice.