THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We are required by law to maintain the privacy of protected health information, 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 in effect. This Notice takes effect 1 / 01 / 2014, and will remain in effect until we
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
You may request a copy of ourNotice at any time.
For more information about our privacy practices, orfor additional
copies of this Notice, please contact us using the information listed at the end of this Notice.
We may use and disclose your health information for different purposes, including treatment, payment, and health
care operations. For each of these categories, we have provided a description and an example. Some information,
such as HIV-related information, genetic information, alcohol and/or substance abuse records, 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 health information for your treatment. For example, we may disclose your
health information to a specialist providing treatment to you.
Payment. We may use and disclose your health information 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 health plan containing certain health
Healthcare Operations. We may use and disclose your health information in connection with our healthcare
operations. For example, healthcare operations include quality assessment and improvement activities, conducting
training programs, and licensing activities.
Individuals Involved in Your Care or Payment for Your Care.We may disclose your health information 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 health information to assist in disaster relief efforts.
Required by Law. We may use or disclose your health information when we are required to do so by law.
Public Health Activities. We may disclose your health information 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 or devices;
Notify a person of a recall, repair, or replacement of products or 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 health information 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 health information 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 a 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.
Research. 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
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 a deceased person or determine the 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 the communications.
Other Uses and Disclosures of PHI
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 for in this 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.
You have the right to look at or get copies of your health information, with limited exceptions. You must make
the request in writing. You may obtain a form to request access by using the contact information listed at the end of
this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request
information that we maintain on paper, we may provide photocopies. If you request information that we maintain
electronically, you have the right to an electronic copy. We will use the form and format you request if readily
producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for
postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an
explanation of our fee structure.
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.
Disclosure Accounting. With the exception of certain disclosures, you have the right to receive an accounting of
disclosures of your health information in accordance with applicable laws and regulations. To request an accounting
of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you
request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for
responding to the additional requests.
Right to Request a Restriction. You have the right to request additional restrictions on our use or disclosure of your
PHI by submitting a written request to the Privacy Official. Your written request must include (1) what information
you want to limit, (2) whether you want to limit our use, disclosure or both, and (3)to whom you want 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
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 health
information by alternative means or at alternative locations. You must make your request in writing. Your request
must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled
under the alternative means or location you request. We will accommodate all reasonable requests. However, if we
are unable to contact you using the ways or locations you have requested we may contact you using the information
Amendment. You have the right to request that we amend your health information. Your request must be in writing,
and it must explain 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 an amendment, we will provide you with a written explanation of why we denied it and explain your
Right to Notification of a Breach. You will receive notifications of breaches of your unsecured protected health
information 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 Web site or by electronic mail (e-mail).
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 health information or in response to a request you made to amend or restrict the use or disclosure of
your health information or to have us communicate with you by alternative means or at alternative 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 health information. We will not retaliate in any way if you choose to file
a complaint with us or with the U.S. Department of Health and Human Services.
Our Privacy Official: Mickie Kerr
Address: 137 N. Oak Park Ave. #202 Oak Park, IL 60301
Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any
other party requires the prior written approval of the American Dental Association. This material is educational only,
does not constitute legal advice, and covers only federal, not state, law. Changes in applicable laws or regulations
may require revision. Dentists should contact their personal attorneys for legal advice pertaining to HIPAA
compliance, the HITECH Act, and the U.S. Department of Health and Human Services rules and regulations.