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 protected health information (i.e., individually identifiable
information, such as names, dates, phone numbers, addresses, social
security numbers, and demographic data) may be used or disclosed by
us in one or more of the following respects:
To other health care providers (your general dentist, oral
surgeon, etc.) in connection with our rendering orthodontic
treatment to you or your dependent;
To third party payors (insurance companies, administrators of
flexible spending accounts, etc.) in order to obtain payment of
To certifying, licensing and accrediting bodies in connection with
obtaining certification, licensure or accreditation;
Internally, to all staff members who have any role in your
To other patients and third parties who may see or overhear
incidental disclosures about your treatment, scheduling, etc.;
To family members involved in your treatment, including
appointment reminders by phone or mail. Any other uses or
disclosures of your protected health information will be made only
after obtaining your written authorization, which you have the
right to revoke.
Under the new privacy rules, you have the right to:
Request restrictions on the use and disclosure of your protected
Request confidential communication of your protected health
Inspect and obtain copies of your protected health information
through asking us;
Amend or modify your protected health information in certain
Receive an accounting of certain disclosures made by us of your
protected health information; and,
You may, without risk of retaliation, file a complaint as to any
violation by us of your privacy rights with us (by submitting
inquiries to our Privacy Contact Person at our office address) or
the United States Secretary of Health and Human Services (which
must be filed within 180 days of the violation).
We have the following duties under the privacy rules:
By law, to maintain the privacy of protected health information
and to provide you with this notice setting forth our legal duties
and privacy practices with respect to such information; and
To advise you of our right to change the terms of this Privacy
Notice and to make the new notice provisions effective for all
protected health information maintained by us and that if we do
so, we will provide you with a copy of the revised Privacy Notice.
Please note that we are not obligated to:
Honor any request by you to restrict the use or disclosure of your
protected health information for treatment, payment or healthcare
Amend your protected health information if, for example, it is
accurate and complete; or
Provide an atmosphere that is totally free of the possibility that
your protected health information may be incidentally overheard by
other patients and third parties.
This privacy notice is effective as of the date of your signature.
By signing, you acknowledge that you have reviewed a copy of this
Notice. If you have any questions about the information in this
Notice, please ask for our Privacy Contact Person. Thank you.