Patient Privacy Policy


 We are required by law to maintain the privacy of protected health information(PHI), 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 effect. This Notice takes effect 9/3/2013 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 a copy of this Notice, please contact us using the information listed at the end of this Notice.


 We may use and disclose your PHI for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description. Some information, such as HIV-related information, alcohol and/or substance abuse 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 PHI for your treatment. For example, we may disclose your health information to your general dentist or treating physician when applicable.

Payment. We may use and disclose your PHI 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 or medical health plans containing certain health information.

Individuals Involved in Your Care or Payment for Your Care. We may disclose your PHI to your family or friends or any other individual identified by you when they are involved 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 PHI to assist in disaster relief efforts.

Required by law. We may use or disclose your PHI when we are required to do so by law.

Public Health Activities. We may disclose your PHI 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/devices

-Notify a person of a recall, repair, or replacement of products/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 PHI 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 PHI 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.

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.

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.

Judicial and Administrative Proceedings. If you are involved in a lawsuit or 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.

  1. 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 the deceased or determine a cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out 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 such communications.


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 in the 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 taken action in reliance on the authorization.


  1. You have the right to look at or get copies of your PHI, with limited exceptions. You must make the request in writing.  You may obtain a form to request access by using the email, fax or physical address listed at the end of this Notice.  You may also request access by sending us a letter.   If you request information we maintain on paper, we may provide you photocopies.  If you request information we maintain electronically, you have the right to an electronic copy.  We will use the form and format that you request if readily producible.  We may charge you a reasonable cost-based fee for the cost of supplies and/or labor. 

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.

Right to Request a Restriction. You have the right to request additional restrictions our use or disclosure of your PHI by submitting a written request.  Your written request must include (1) what information you would like limited, (2) whether you’re limiting our use, disclosure or both, and (3) to whom you would like 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 the 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 PHI by alternative means or at alternative locations. You must make your request in writing, specifying the alternative means or location, and provide a satisfactory explanation of how payments will be handled under the alternative means or location you request.  We will accommodate reasonable requests.  However, if we are unable to contact you using the means or locations requested, we may contact you using the information we have.

Amendment.   You have the right to request that we amend your PHI. Your request must be submitted in writing with explanation as to 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 amendment, we will provide you with a written explanation for the denial and explain your rights.

Right to Notification of a Breach.  You will receive notifications of breaches of your unsecured PHI 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 website.


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 PHI or in a response to a request you made to amend or restrict the use or disclosure of your information or to have us communicate with you by alternative means or 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 PHI. We will not retaliate if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.