Privacy Policy Notice
Notice of Privacy Practices
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.
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 February
16, 2026 and will remain in effect until 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, 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 use disorder treatment records,
and mental health records may be entitled to special confidentiality
protections under applicable state or 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.
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 receive 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.
reimbursement for the treatment and services you receive 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.
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 for Your Care.
We may disclose your health information to your family or friends or any
other individual identified by you when they participate 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.
other individual identified by you when they participate 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.
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.
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 medications or problems with products 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 the victim of abuse, neglect, or domestic violence.
public health activities, including disclosures to:
• Prevent or control disease, injury or disability;
• Report child abuse or neglect;
• Report reactions to medications or problems with products 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 the victim of 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 to authorized federal officials health
information required for lawful intelligence, counterintelligence, and
other national security activities. We may disclose to correctional
institution or law enforcement official having lawful custody the
protected health information of an inmate or patient.
information of Armed Forces personnel under certain
circumstances. We may disclose to authorized federal officials health
information required for lawful intelligence, counterintelligence, and
other national security activities. We may disclose to correctional
institution or law enforcement official 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 the U.S. Department of Health and Human Services
when required to investigate or determine compliance with HIPAA.
Worker’s Compensation. We may disclose your PHI to the extent
authorized by and to the extent necessary to comply with laws
relating to worker’s compensation or other similar programs
established by law.
Secretary of the U.S. Department of Health and Human Services
when required to investigate or determine compliance with HIPAA.
Worker’s Compensation. We may disclose your PHI to the 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 your PHI for law enforcement
purposes as permitted by HIPAA, as required by law, or in response
to a subpoena or court order.
purposes as permitted by HIPAA, as required by law, or in response
to a subpoena or court order.
Health Oversight Activities.
We may disclose your 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.
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.
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 your 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 of your information.
Coroners, Medical Examiners, and Funeral Directors. We may
release your 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 perform
their duties.
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 of your information.
Coroners, Medical Examiners, and Funeral Directors. We may
release your 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 perform
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.
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.
SUD Treatment Information.
If we receive or maintain any information
about you from a substance use disorder treatment program that is
covered by 42 CFR Part 2 (a “Part 2 Program”) through a general
consent you provide to the Part 2 Program to use and disclose the Part
2 Program record for purposes of treatment, payment or health care
operations, we may use and disclose your Part 2 Program record for
treatment, payment and health care operations purposes as described
in this Notice. If we receive or maintain your Part 2 Program record
through specific consent you provide to us or another third party, we
will use and disclose your Part 2 Program record only as expressly
permitted by you in your consent as provided to us.
In no event will we use or disclose your Part 2 Program record, or
testimony that describes the information contained in your Part 2
Program record, in any civil, criminal, administrative, or legislative
proceedings by any Federal, State, or local authority, against you,
unless authorized by your consent or the order of a court after it
provides you notice of the court order.
about you from a substance use disorder treatment program that is
covered by 42 CFR Part 2 (a “Part 2 Program”) through a general
consent you provide to the Part 2 Program to use and disclose the Part
2 Program record for purposes of treatment, payment or health care
operations, we may use and disclose your Part 2 Program record for
treatment, payment and health care operations purposes as described
in this Notice. If we receive or maintain your Part 2 Program record
through specific consent you provide to us or another third party, we
will use and disclose your Part 2 Program record only as expressly
permitted by you in your consent as provided to us.
In no event will we use or disclose your Part 2 Program record, or
testimony that describes the information contained in your Part 2
Program record, in any civil, criminal, administrative, or legislative
proceedings by any Federal, State, or local authority, against you,
unless authorized by your consent or the order of a court after it
provides you notice of the court order.
OTHER USES AND DISCLOSURES OF PHI
Your authorization is required, with a few exceptions, for disclosure of
psychotherapy notes, use or disclosure of PHI for marketing, and for
the sale of PHI. We will also obtain your written authorization before
using or disclosing your PHI for purposes other than those provided
for in this Notice (or as otherwise permitted or required by law). You
may 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 acted 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 exceptions. You must make the request in
writing. You may obtain a form to request access by using the
contact information listed at the end of this Notice. You may also
request access by sending us a letter to the address at the end of
this Notice. 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. We
will charge you a reasonable cost–based fee for the cost of supplies
and labor of copying, and for postage if you want copies mailed to
you. Contact us using the information listed at the end of this
Notice for an explanation of our fee structure.
If you are denied a request for access, you have the right to have the
denial reviewed in accordance with the requirements of applicable law.
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 request this accounting more than once in a
12–month period, we may charge you a reasonable, cost–based fee for
responding to the additional requests.
Right to Request a Restriction.
You have the right to request additional restrictions on our use or disclosure of your 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
your request except in the case where the disclosure is to a health
plan for purposes of carrying out 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 the health
plan), has paid our practice in full.
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
your request except in the case where the disclosure is to a health
plan for purposes of carrying out 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 the 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 locations. 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 requests. 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 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 we agree to your
request, we will amend your record(s) 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 notifications of
breaches of your unsecured protected health information as
required by law.
alternative means or at alternative locations. 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 requests. 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 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 we agree to your
request, we will amend your record(s) 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 notifications of
breaches of your 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 Web site or by electronic mail (e–mail).
request, even if you have agreed to receive this Notice electronically
on our Web site or by electronic mail (e–mail).
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have
questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights,
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 at alternative
locations, you may complain to us using the contact information
listed at the end of this Notice. You also may submit a written
complaint to the U.S. Department of Health and Human Services.
We will provide you with the address to file your complaint with the
U.S. Department of Health and Human Services 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 U.S. Department of Health and Human Services.
PRIVACY OFFICIAL CONTACT INFORMATION:
Telephone: 561-332-3644
Telephone: 561-332-3644
This material is educational only, does not constitute legal advice, and covers only federal, not state, law. Changes in applicable laws or regulations may require revision. Dentists should contact their personal attorneys for
legal advice pertaining to HIPAA compliance, the HITECH Act, and the U.S. Department of Health and Human Services rules and regulations. Reproduction of this material by dentists and their staff is permitted. Any other
use, duplication or distribution by any other party requires the prior written approval of the American Dental Association. This material is educational only, does not constitute legal advice, and covers only
federal, not state, law. Changes in applicable laws or regulations may require revision. Dentists should contact their personal attorneys for legal advice pertaining to HIPAA compliance, the
HITECH Act, and the U.S. Department of Health and Human Services rules and regulations.
© 2010–2025 American Dental Association. All Rights Res
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