NOTICE OF PRIVACY PRACTICES

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

The most common reason why we use or disclose your health information is for treatment, payment, or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; examining your teeth; prescribing medications and faxing them to be filled referring you to another doctor or clinic for other health care or services or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or dental care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions participation in managed care plans; defense of legal matters business planning and outside storage of our records.

We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we usually will not ask you for special written permission.

Special Protections for Substance Use Disorder (SUD) Records

For patients receiving treatment for substance use disorders, federal law (42 CFR Part 2) provides additional privacy protections beyond standard health information.

• Heightened Confidentiality: We will not disclose records identifying you as having a substance use disorder in civil, criminal, administrative, or legislative proceedings without your specific written consent or a specialized court order.
• Single Consent for TPO: You may choose to provide a single, written “Global Consent” that allows us to use and disclose your SUD records for all future treatment, payment, and health care operations.
• Right to Revoke: You have the right to revoke this consent at any time in writing, except to the extent that we have already taken action based on your prior permission.
• Accounting of Disclosures: You have the right to request a list of certain disclosures of your SUD records made for treatment, payment, and health care operations for the three years prior to your request.
• Prohibition on Redisclosure: Anyone receiving your SUD records is generally prohibited from sharing that information further unless you provide express written consent or the law specifically permits it.

We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we usually will not ask you for special written permission.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

• When a state or federal law requires certain health information to be reported for a specific purpose.
• For public health purposes, such as contagious disease reporting, investigation or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices.
• Disclosures to governmental authorities about victims of suspected abuse, neglect, or domestic violence.
• Uses and disclosures for health oversight activities, such as licensing of doctors, audits by Medicare or Medicaid, or investigation of possible violations of health care laws.
• Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies.
• Disclosures for law enforcement purposes, such as providing information about a crime or a suspected victim.
• Disclosure to a medical examiner to identify a deceased person or determine the cause of death, to funeral directors for burial purposes, or to organizations handling organ or tissue donations.
• Uses or disclosures for health-related research.
• Uses and disclosures to prevent a serious threat to health or safety.
• Uses or disclosures for specialized government functions, such as protection of the President, national intelligence activities, military purposes, or evaluation of foreign service members.
• Disclosures of de-identified information.
• Disclosures related to workers’ compensation programs.
• Disclosures of a limited data set for research, public health, or health care operations.
• Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures.
• Disclosures to business associates who perform health care operations and agree to protect the privacy of health information.

Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your dental care.

NOTIFICATION OF DATA BREACHES

We are required by law to maintain the privacy and security of your protected health information. In the event of a breach—which is the unauthorized acquisition, access, use, or disclosure of your unsecured health information—we will notify you promptly. This notice will be provided in writing via first-class mail (or via email if you have previously agreed to electronic communications) and will include a description of what happened, the types of information involved, and the steps we are taking to investigate the breach, mitigate losses, and protect against further occurrences.

APPOINTMENT REMINDERS

We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a postcard, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.

TELEHEALTH / VIRTUAL VISITS AND ELECTRONIC COMMUNICATIONS

From time to time, we may offer telehealth (virtual) visits or communicate with you electronically (for example, through a patient portal, secure video, email, or text) to provide care, answer questions, coordinate treatment, send reminders, or discuss billing matters. When we provide telehealth services, we may use technology vendors to help us deliver these services. These vendors may receive limited protected health information as needed to provide the service and are required to protect your information and may be required to sign a business associate agreement with us, as applicable. You may request that we communicate with you in a confidential way (for example, using a specific phone number, mailing address, email address, or through the patient portal). See the “Confidential Communications” right described in the Notice. Please tell us if you want to opt out of electronic communications or prefer a different method. Electronic communications can carry some risk of interception or misdelivery. We use reasonable safeguards to protect your information, and we encourage you to use secure methods (such as the patient portal) when available. If you choose to communicate with us by unencrypted email or text, you are acknowledging and accepting those risks.

If you have questions about telehealth or electronic communications, contact the office contact person listed at the beginning of the Notice.

OTHER USES AND DISCLOSURES

We will not make any other uses or disclosures of your health information unless you sign a written “authorization form.” The content of an “authorization form” is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it’s your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice.

Uses and Disclosures Requiring Your Authorization

Most uses and disclosures of your health information for marketing purposes, and disclosures that constitute a sale of your health information, require your written authorization. Other uses and disclosures not described in this Notice will be made only with your written authorization. You may revoke such an authorization at any time in writing.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

The law gives you many rights regarding your health information. You can:

• Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment, or health care operations. We are not required to agree, but if we do agree, we must honor the restriction. To request a restriction, send a written request to the office contact person at the address, fax, or email listed at the beginning of this Notice.
• Ask us to communicate with you in a confidential way, such as calling you at work instead of home, mailing information to a different address, or emailing your personal email address. We will accommodate reasonable requests if you agree to pay any additional costs. To request confidential communication, send a written request to the office contact person listed at the beginning of this Notice.
• Ask to see or get copies of your health information. In limited situations, we may deny access. Generally, you will receive access within 30 days (or 60 days if stored off-site). You may need to pay in advance for copies. If denied, we will provide a written explanation and instructions for review if available. We may take one 30-day extension with written notice. To request access, send a written request to the office contact person listed at the beginning of this Notice.
• Ask us to amend your health information if it is incorrect or incomplete. If we agree, we will amend it within 60 days and notify relevant parties. If we deny your request, you may submit a written statement of disagreement, which will be included with your records. We may take one 30-day extension with written notice. To request an amendment, send a written request with your reasons to the office contact person listed at the beginning of this Notice.
• Request a list of disclosures made in the past six years (or shorter period if requested). The list will not include disclosures for treatment, payment, health care operations, those made with your authorization, incidental disclosures, disclosures required by law, and certain other limited disclosures. One list per year is free; additional requests require advance payment. We usually respond within 60 days but may take one 30-day extension with written notice. To request this list, send a written request to the office contact person listed at the beginning of this Notice.
• Request additional paper copies of this Notice of Privacy Practices, even if you previously received it electronically or in paper form. To request copies, send a written request to the office contact person listed at the beginning of this Notice.
• Restrict disclosures for out-of-pocket payments. If you pay in full out-of-pocket for a dental service or health care item, you may request that we not share that information with your dental insurance or health plan for payment or operations purposes. We are required by law to agree unless another law requires us to share the information.

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 website.

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 email 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.