Patient privacy Policy

This Notice of Privacy Practices  present the information that federal law requires us to give our patients regarding our use of your private health care information. 


This Notice describes the privacy policies for this dental office. First and foremost, we strive to maintain confidentiality as far as your dental treatment information. There are times, however, where identifiable health information must be disclosed to specific entities such as your insurance carrier. Herein we describe how this confidential dental and health information is used and disclosed and how you can gain access to this confidential information. Please review it carefully. Dental offices are required by applicable federal and state laws to maintain confidentiality of dental health information generated for patients during course of treatment. Through recent legislation, dental offices are now required to notify all patients about privacy practices, or legal duties concerning these practices, and your rights concerning your health information. These office privacy policies take effect as of January 1, 2006 and will remain in effect until amended by this office. Please keep this information on file and check with our Privacy Officer for any amended versions or changes.



In addition to our use of your heath information for treatment, payment, or dental practice operations, you may give us written authorization to use your health information or to disclose in to anyone for any purpose. If you give us such an authorization, you have the right to revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.

  • You have the right to request that we place additional restrictions on our use or disclosure of your dental health information. We reserve the right to discuss your request and we are not required to agree to your additional restrictions. If we agree to abide by your request, however, we may be exempted from this agreement in the event of an emergency.
  • You have the right to read over or obtain copies of your dental health information, with limited exceptions. You may request in person or in writing to obtain access to your dental information. You will be charged a reasonable cost-based fee for expenses such as copies and staff time. You will be asked to sign a brief authorization to obtain copies of your records. You may contact the privacy officer listed at the end of this Notice for a full explanation of our duplication fee structure. ·
  • You have the right to receive a list of insurances in which this practice disclosed your dental information for purposes other than treatment, payment, dental practice operations and certain activities for the six month period starting April 15, 2003 and at any six month interval thereafter. If you request this accounting more than once in a twelve month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
  • You have the right to request that we communicate with you about your dental health information by alternative means to alternative locations (fax or e-mail, for example). You must make your request in writing. Your request must specify the alternative means or location.


  • You have the right to request that we amend your dental health information that has been provided to you. Your request must be in writing and it must explain why the information should be amended. We reserve the right to deny your request under certain circumstances.



This office uses and discloses heath information about you and/or your family members for the purposes of treatment, payment and dental practice operations. Examples are provided, but not all possible uses or disclosures are listed.


For Treatment: We may use or disclose your dental health information to dental colleagues, your physician or other health care providers rendering treatment.

For Payment: We may use and disclose your dental treatment information through regular mail, fax, or electronic transmission to your dental insurance carrier to obtain payment for services rendered. Limited treatment information may also be disclosed to billing services, which assist the office in preparing monthly billing statements.

For Health Care Operations: We may use and disclose your health information in conjunction with our health care operations to assure that you receive quality care. For example, we may use medical information to review our treatment and services and evaluate the performance of our staff in caring for you.

Other Uses or Disclosures That Can Be Made Without Your Consent or Authorization:

  • As required during an investigation by law enforcement agencies.
  • In the event of your incapacity or emergency circumstances.
  • We will not use your dental health information or images of your face and/or teeth for marketing communications without your specific written authorization to do so.
  • To appropriate authorities if we have reason to believe that they are possible victims of abuse, neglect, or domestic violence or the possible victim of other crimes.
  • To authorized federal officials dental information required for lawful intelligence, counterintelligence, and other national security activities.
  • As required by the US Food and Drug Administration (FDA).
  • To provide appointment reminders such as voicemail messages, postcards, letters, or e-mail messages.