Notice of Privacy Practices

Your Choices

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds

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

Your Rights

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health 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-based fee.

Ask us to correct your medical 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’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact 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 requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• 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’ll provide one accounting per year for free but may charge a reasonable, cost-based fee if you ask for another within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive it electronically.

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 verify that this person has authority to act for you.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us.
• You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights:
  Address: 200 Independence Ave., S.W., Washington, D.C. 20201
  Phone: 1-877-696-6775
  Website: www.hhs.gov/ocr/privacy/hipaa/complaints/

Your Choices for Certain Uses & Disclosures

You can tell us your preferences for how we share information in these situations:

• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory

If you are not able to tell us your preference, we may share your information if we believe it is in your best interest.

We Never Share Without Your Written Permission

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

Fundraising

We may contact you for fundraising, but you can tell us not to contact you again.

Our Uses and Disclosures

We typically use or share your health information to:

Treat you – Share with professionals treating you
Run our organization – Improve care and manage services
Bill for services – Get payment from health plans

Other Uses Required or Allowed by Law

We may also share your information to:

• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and government requests
• Respond to lawsuits and legal actions

Special Considerations for SUD Records

If we receive substance use disorder (SUD) records, we will only use and disclose them according to HIPAA and applicable laws. We will not use them for fundraising and will not release them without proper legal authorization.

Our Responsibilities

• Maintain the privacy and security of your protected health information
• Notify you promptly if a breach occurs
• Follow the practices described in this notice
• Not use or share your information unless allowed or you give written permission

Changes to This Notice

We may change the terms of this notice, and the changes will apply to all information we have about you. The updated notice will be available in our office and on our website.

Date of Posting: 2022
Privacy Officer: Alexis Meyers, DMD
Phone: 4123135176