NOTICE OF PRIVACY PRACTICES
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.
UNDERSTANDING YOUR HEALTH INFORMATION
Each time you visit our office, we make a record of your visit in order to manage the care you receive.
We understand that the medical information that is recorded about you and your health is personal. The
confidentiality and privacy of your health information is also protected under both state and federal law.
This Notice of Privacy Practices describes how this office may use and disclose your information and the
rights that you have regarding your health information.
How We Will Use or Disclose Your Health Information
Treatment: We will use your health information for treatment. For example, information obtained by the
orthodontist or other members of your healthcare team will be recorded in your record and used to
determine the course of treatment that should work best for you. Your orthodontist will document in your
record his or her expectations of the members of your healthcare team. Members of your healthcare team
will then record the actions they took and their observations, so the physician will know how you are
responding to treatment. We will also provide your physician, or a subsequent healthcare provider, with
copies of various reports that should assist him or her in treating you.
Payment: We will use your health information for payment. For example, a bill may be sent to you or
your health plan. The information on or accompanying the bill may include information that identifies
you, as well as your diagnosis, procedures, and supplies used.
Health Care Operations: We will use your health information for our regular health care operations. For
example, we may use information in your health record to assess the care and outcome in your case and
others like it. This information will then be used in a continued effort to improve the quality and
effectiveness of the services we provide.
Business Associates: We may enter into contracts with persons or entities known as business associates
that provide services to or perform functions on our behalf. Examples include our accountants,
consultants, and attorneys. We may disclose your health information to our business associates so they
can perform the job we have asked them to do, once they have agreed in writing to safeguard your
Notification: We may use or disclose information to assist in notifying a family member, personal
representative, or another person responsible for your care, of your location, and general condition. If we
are unable to reach your family member or personal representative, then we may leave a message for
them at the phone number that they have provided to us, e.g., on an answering machine.
Communication with Family: We may disclose to a family member, other relative, close personal friend
or any other person you identify, health information relevant to that person’s involvement in your care or
payment related to your care.
Appointment Reminders / Health Benefits: We may contact you to provide appointment reminders or
information about treatment alternatives or other health benefits that may be of interest to you.
Funeral Directors and Coroners: We may disclose your health information to funeral directors, and to
coroners or medical examiners, to carry out their duties consistent with applicable law.
Organ Procurement Organizations: Consistent with applicable law, we may disclose your health
information to organ procurement organizations or other entities engaged in the procurement, banking, or
transplantation of organs for the purpose of tissue donation and transplant.
Research: We may disclose your health information to researchers when their research has been approved
by an institutional review board that has reviewed the research proposal and established protocols to
ensure the privacy of your health information. We may also disclose your health information to people
preparing to conduct a research project, so long as the health information is not removed from us. We
may also use and disclose your health information to contact you about the possibility of enrolling in a
Fundraising: We may contact you as part of our fundraising efforts; however, you may opt-out of
receiving such communications.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to
adverse events with respect to food, supplements, product, and product defects, or post marketing
surveillance information to enable product recalls, repairs, or replacement.
Workers’ Compensation: We may disclose health information to the extent authorized by and to the
extent necessary, to comply with laws relating to workers’ compensation or other similar programs
established by law.
Public Health Activities: As required by law, we may disclose your health information to public health, or
legal authorities, charged with preventing or controlling disease, injury, or disability.
Health Oversight Activities: We may disclose your health information to health oversight agencies for
purposes of legally authorized health oversight activities, such as audits and investigations necessary for
oversight of the health care system and government benefit programs.
Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the
institution, or agents thereof, health information necessary for your health and the health and safety of
Judicial and Administrative Proceedings: We may disclose your health information in a judicial or
administrative proceeding if the request for the information is through an order from a court or
administrative tribunal. Such information may also be disclosed in response to a subpoena or other lawful
process if certain assurances regarding notice to the individual or a protective order are provided.
Law Enforcement Purposes / Serious Threat to Health or Safety: We may disclose your health
information to enforcement officials for law enforcement purposes under certain circumstances and
subject to certain conditions. We may also disclose your health information to prevent or lessen a serious
and imminent threat to a person or the public (when the disclosure is made to someone we believe can
prevent or lessen the threat) or to identify or apprehend an escapee or violent criminal.
Victims of Abuse, Neglect, and Domestic Violence: In certain circumstances, we may disclose your
health information to appropriate government authorities if there are allegations of abuse, neglect, or
Essential Government Functions: We may disclose your health information for certain essential
government functions (e.g., military activity and for national security purposes).
The following uses and disclosures will be made only with your authorization: (i) with limited
exceptions, uses and disclosures of your health information for marketing purposes, including subsidized
treatment communications; (ii) disclosures that constitute a sale of your health information; and (iii) other
uses and disclosures not described in this notice. You may revoke your authorization at any time in
writing, except to the extent that we have taken action in reliance on the use or disclosure indicated in the