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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.

Your Rights:

When it comes to your health information you have certain rights. The section explains your rights and some of our responsibilities to help you.

  • Get an electronic or paper copy of your dental record
    • You can ask to see r get an electronic or paper copy of your dental and other healthy information we have about you. Ask us how to do this
    • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-base fee.
  • Ask us to correct your dental record
    • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
    • We may say “no” to your request but we will tell you why in writing within 60 days.
  • Request confidential communications
    • You can ask us to contacts you in a specific way (for example home or office phone) or to send mail to a different address.
    • We will say “yes” to all reasonable request
  • Ask us to limit what we use or share
    • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with and why
    • We will include all the disclosures except for those about treatment, payment and heal care operations, and any other disclosures you asked us to make
    • Well provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months
  • Choose someone to act for you
    • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information
    • We will make sure the person has this authority and can act for you before we take any action.
  • File a complaint if you fell your rights are violated
    • You can file a complaint with the U.S department of Health and Human Service for civil Rights by sending a letter to 200 Independence Ave, S.W., Washington D.C. 20201, by calling 1-877-696-6775 or by visiting
    • We will not retaliate against you for filling a complaint

Your Choices:

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations describe below, talk to us. Tell us what you want us to do, and we will follow your instructions.

  • You have both the right and the choice to tell us we can:
    • Share information with your family, close friends
    • Share information with other involved in payment for your care
  • Unless you give us written permission, we never share your information for marketing purpose or sell your information

Our Uses and Disclosures

We typically use or share your health information in the following way:

  • Treat you
    • We can use your health information and share it with other professionals who are treating you
    • Example: we need to refer you to a specialist for treatment, and may forward information about your condition
  • Run our organization
    • We can use and share your information to run our practice, improve your care and contact you when necessary.
    • Example: we use health information about you to manage your treatment and services
  • Bill your services
    • We can use and share your health information to bill and get payment from insurance plan or other entities
    • Example: we give information about you to your insurance plan so it will pay for your services

How else can we use or share your health information?

  • We are allowed or required to share your information in other ways- usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:
  • Prevent disease
  • Helping with product recalls
  • Reporting adverse reactions to medications
  • Reporting suspected abuse, neglect, or domestic violence
  • Preventing or reducing a serious threat to anyone’s health or safety
  • Do research
    • We can use or share your information for health research
  • Comply with the law
    • We will share information about you if state or federal laws require it, including to the Department of Health and Human Services if it wants to see that were complying with federal policy law.
    • We can share health information with a corner or medical examiner when an individual dies
  • Address workers’ compensation, law enforcement and other government request
    • We can use or share health information about you for workers’ compensation claims
    • We can share health information about you with health oversight agencies for activities authorized by law
  • Respond to lawsuits and legal actions
    • We can share health information about you in response to a court or administrative order or in response to a subpoena.

Our reasonability’s 

  • We are required by law to maintain the privacy and security of your protected health information
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information
  • We must follow the duties and privacy practices described in this notice and give you a copy of it
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
  • For more information see:

Change to the terms of this notice

We can change the terms of this notice and the changes will apply to all information we have about you. The new notice will be available upon request, in our office and on our web site.

Effective Date: July 1st 2016

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