HIPPA

Statement of Privacy Practices

This statement of privacy practices describes how dental information about you may be
disclosed and how you can get access to this information. Please read carefully

Our practice collects and maintains a record of the health care services we provide you. In keeping with
the Health Insurance Portability and Accountability Act (HIPAA), and current state regulations we are
dedicated to protect your rights of privacy and the confidential information entrusted to us.
The commitment of each employee to ensure that your health information is never compromised is a
principal concept of our practice. We will not disclose your protected health information unless you direct
or authorize us to do so or unless it is otherwise allowed or compelled by law. We may, from time to time,
amend our privacy policies and practices but will always inform you of any changes that might affect your
rights.
You may see your record or get more information about it at “Your Individual Rights about Patient Health
Information” section of the Notice. You may request to review and copy your personal record and you may
also request that we make corrections to the record.

OVERVIEW

Our Statement of Privacy Practices is currently in effect and provides information about the use and
disclosure of protected health information by our practice and our employees. It is applicable in all
instances wherein individually identifiable health information is collected from you and services are provided
for you. Our Statement:
1. Defines your rights and our obligations when using your health Information,
2. Informs you about laws that provide special protections,
3. Explains how your protected health information is used and how, under certain circumstances,
it may be disclosed,
4. Tells you how changes in this statement will be made available to you.
In synopsis form, you have a right to:
1. Request restricted use of your health information. (Please understand that we may not agree
to your request),
2. Request that we not disclose to your health plan of services for which you self-pay in full,
3. Request that we communicate with you by alternate methods,
4. Review and receive copies of your personal health record,
5. Request for amendments and/or changes be made to your record,
6. Request an accounting of disclosures of your health information,
7. File complaints related to failure to protect the privacy of your health information,
8. Direct us not to share information with your family members,
9. Request that you not be listed in/on our facility directory,
10. Be informed that some regulations, such as those addressed under Substance Use Disorder
rules are more restrictive than HIPAA rules.

PROTECTED HEALTHCARE INFORMATION (PHI)

It is important that you know not only that we limit requests for your personal information to that needed
to provide quality health care, implement payment activities, and conduct normal health practice
operations, but understand what “Protected Healthcare Information” is. This may include your name,
address, telephone number(s), Social Security Number, employment data, dental history, health records,
and/or any personal information that is unique to you.
While most of the information will be collected from you, we may obtain information from third parties if it
is deemed necessary. Regardless of the source, your personal information will always be protected to the
full extent of the law.

PROTECTING YOUR PERSONAL HEALTHCARE INFORMATION

We use and disclose the information we collect from you only as allowed by the HIPAA and the state
regulations. This includes when it is used and disclosed to perform treatment, obtain payment, and conduct
operational activities. Your personal health information will never be otherwise given to anyone – even
family members – without your written consent. You, of course, may give written authorization for us to
disclose your information to anyone you choose, for any purpose.
Our Statement of Privacy Practices applies to all personal health information collected or created by our
employees or received from outside healthcare providers. This information may identify you, relate to your
past, present or future physical or mental condition, the care provided, or any reference to payment for
your health care.
For example, protected health information includes symptoms, test results, diagnoses, health information
from other providers, as well as billing and payment information relating to these services. This information
is protected because it is often part of your health or dental record, which we can use as:
1. A method of communication among health professionals who contribute to your care,
2. A legal record describing the care you received,
3. A means by which you can verify that services billed were provided,
4. A tool to educate health professionals,
5. A source of data for dental research,
6. A source of information for public health officials,
7. A source of information for facility planning,
8. A tool to assess and improve the care we provide,
9. A method by which we can provide a better understanding of your record,
10. A method by which we can ensure your record’s accuracy,
11. A system to assist you to more clearly understand the circumstances and conditions in and by
which others may have access to your personal information.
12. A tool for us to make more informed decisions when authorizing disclosures to others.

PHI USE AND DISCLOSURE– WITHOUT YOUR AUTHORIZATION

As stated above we may, under allowed circumstances use and disclose protected health information (PHI)
without your specific authorization. Examples of such instances are included below:
Treatment: We may use and disclose your PHI to provide treatment. For example, we can:
1. Use your information to find out whether certain tests, therapies, and medicines should be
ordered,
2. Provide your information to staff members to better understand what your healthcare needs
are how to evaluate your response to treatment,
3. Disclose your PHI to another one of your treatment providers in order to provide you with the
best possible health care.
4. Share, with your consent and authorization, PHI relating to substance use disorder with
substance disorder treatment programs, doctor’s offices, and health care businesses for those
activities

Payment: We may use your health information for payment purposes. Such instances may include:
1. Preparation of claims for payment of services,
2. Billing your insurance directly, including information that identifies you, as well as your
diagnosis, the procedures performed, and supplies used so that we can be paid for the
treatment provided,
3. Collection activities (if necessary) to obtain payment for services.
Health Care Operations: We may use and disclose your health information to support the daily activities
related to health care. Examples include:
1. Use and disclosure to monitor and improve our health services.
2. Use by authorized staff to review at portions of your record to perform administrative activities.
Train Staff and Students: We may use and disclose your information to teach and train staff how to
review patient health information.
Contact You for Information: Your PHI may also be used to contact you. In example, we may call you or
send you a letter to remind you about your appointment, provide test results, inform you about treatment
options, or advise you about other health-related benefits and services.
Business Associates. Your PHI may be used and disclosed as needed to individuals, organizations, or
companies to comply with our legal obligations described in this Notice. An example is disclosure of your
PHI to consultants, attorneys, or third parties to assist in our business activities. All such entities must sign
a Business Associate Agreement to protect the confidentiality of your private information.

ADDITIONAL USES AND DISCLOSURES

We also use and disclose your information to enhance health care services, protect patient safety, safeguard
public health, ensure that our facilities and staff comply with government and accreditation standards, and
when otherwise compelled or allowed by law not in conflict with exceptions established under HIPAA’s
Substance Use Disorder requirements. For example, we may provide or disclose information:
1. About FDA-regulated drugs and devices to the U.S. Food and Drug Administration.

2. To government oversight agencies with data for health oversight activities such as auditing or

licensure.
3. To public health authorities with information on communicable diseases and vital records.
4. To your employer, findings relating to the evaluation of work-related illnesses or injuries.
5. To workers’ compensation agencies and self-insured employers for work-related illness or
injuries.
6. To appropriate government agencies when we suspect abuse or neglect.
7. To appropriate agencies or persons when we believe it necessary to avoid a serious threat to
health or safety or to prevent serious harm.
8. To organ procurement organizations to coordinate organ donation activities.
9. To law enforcement when required or allowed by law, including the Office of Civil Rights to
conduct OCR investigations.
10. For court order or lawful subpoena (see note below).
11. To coroners, medical examiners, and funeral directors.
12. To government officials when required for specifically identified functions such as national
security.
13. When otherwise required by law, such as to the Secretary of the United States Department of
Health and Human Services for purposes of determining compliance with our obligations to
protect the privacy of your health information.
14. If you are a member of the armed forces, we may release dental information about you as
required by military command authorities. We may also release dental information about
foreign military personnel to the appropriate foreign military authority.

NOTE: If PHI is disclosed pursuant to the HIPAA Privacy Rules’ Substance Use Disorder allowances and
requirements, the records could potentially be redisclosed and will no longer be protected under the
HIPAA Privacy Rule.

YOUR RIGHTS TO OBJECT

Disclosure to Family, Friends, or Others. You may object to our disclosing your general health condition
(“good”, “fair”, “critical”, etc.) to an individual, or individuals, you have identified who have an active
interest in your care, payment for your health care, or who may need to notify others about your general
condition, location, or death. If you do not so indicate, we will use our best professional judgment to
provide relevant protected health information to your family member, friend, or another identified person.
USE AND DISCLOSURES REQUIRING AUTHORIZATION
Our offices and electronic systems are secure from unauthorized access and our employees are trained to
make certain that the confidentiality of your records is always protected. Our privacy policy and practices
apply to all former, current, and future patients, so you can be confident that your protected health
information will never be improperly disclosed or released.
Other than the uses and disclosures described above, we will not use or disclose your protected health
information without your written authorization. You may revoke your written authorization, at any time
unless prohibited by law, or disclosure is required for us to obtain payment for services already provided,
or we have otherwise relied on the authorization.
Your PHI will not be released for use in legal proceedings against your unless (a) you consent or otherwise
authorize its release or the release is based on a Part 2 court order and a subpoena, or similar legal
requirement.

ADDITIONAL PROTECTION

Special state and federal laws apply to certain classes of patient health information. For example, additional
protections may apply to information about sexually transmitted diseases, drug and alcohol abuse
treatment records, mental health records, and HIV/AIDS information. When required by law, we will obtain
your authorization before releasing this type of information.
YOUR INDIVIDUAL RIGHTS
You may contact us to exercise your rights related to the use and disclosure of your protected health
information.
Your specific rights are listed below and include:
1. The right to request restricted use: You may request in writing that we not use or disclose
your information for treatment, payment, and/or operational activities except when authorized
by you, when required by law, or in emergency circumstances. We are not legally required to
agree to your request. If you request that we restrict the use of your private information, we
will provide you with written notice of our decision about your request.
2. The right to request non-disclosure to health plans: You have the right to request in writing
that health care items or services for which you self-pay for in full in advance of your visit not
be disclosed to your health plan.
3. The right to receive confidential communications: You have the right to request that we
communicate with you about dental matters in a particular way or at a certain location. For
example, you can ask that we only contact you at work or by mail. To request confidential
communications, you must make your request in writing to the address above. We will grant
all reasonable requests. Your request must specify how or where you wish to be contacted.
4. The right to inspect and receive copies: In most cases, you have the right to inspect and
receive a copy of certain health care information including certain dental and billing records. If
you request a copy of the information, we may charge a fee for the costs of copying, mailing
or other supplies associated with your request.
5. The right to request an amendment to your record: If you believe that information in your
record is incorrect or that important information is missing, you have the right to request in
writing that we make a correction or add information. In your request for the amendment, you
must give a reason for the amendment. We are not required to agree to the amendment of
your record, but a copy of your request will be added to your record.
6. The right to know about disclosures: You have the right to receive a list of instances in
which we have disclosed your health information. Certain instances will not appear on the list,
such as disclosures for treatment, payment, or health care operations or when you have
authorized the use or disclosure. Your first accounting of disclosures in a calendar year is free
of charge. Any additional request within the same calendar year requires a processing fee.
7. The right to make complaints: If you believe that we have violated your privacy, or you
disagree with a decision we made about access to your records, you may file a complaint
directly to our doctor or any member of our workforce with directions that it be relayed to our
doctor in charge.

Statement of Privacy Practices

You may also contact:

U.S. Department of Health and Human Services,

Office for Civil Rights:
2201 Sixth Avenue – Mail Stop RX-11
Seattle, WA 98121-1831
206-615-2290; 206-615-2296 (TTY)
206-615-2297 (fax)

Toll free: 1-800-362-1710; 1-800-537-7697 (TTY)

BREACH NOTIFICATION

If it is found that your patient information is used or disclosed in a manner that is not consistent with the
practices described in this notice, the incident will be fully investigated to assess if there was a breach in
the protection of your PHI. The assessment will be conducted to determine whether the information
disclosed has significant risk of physical, financial, or reputational harm to you. If so, we will notify you and
submit appropriate information to OCR and the United States Department of Health and Human Services
in writing.

PRIVACY NOTICE CHANGES

We are required by law to protect the privacy of your information, to provide this Statement of Privacy
Practices and to follow the privacy practices that are described herein. We reserve the right to change the
privacy practices described and the right to make the revised or changed Statement effective for protected
health information we already have as well as any information we may receive in the future.
We have posted a copy of our current Statement for your review and reference. Additionally, each time
you visit our office for treatment or health care services, you may request a copy of our current Statement
of Privacy Practices. An electronic version of the notice is posted on our web site.