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. The privacy of your health is important to us.

Our Legal Duty

We are required by law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect.

Changes to This Notice

We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information we currently have about you as well as any information we receive in the future. We will post a copy of the current Notice, with the effective date in the upper right corner of the first page. You may request a copy of our Notice at any time.

Uses and Disclosure of Health Information

We may use and disclose health information about you for treatment, payment, and health care operations. For example:

Treatment

We may use and disclose your health information to another dentist or health care provider providing treatment to you, or if we refer you to another health care provider.

Payment

We may use and disclose your health information to obtain payment for services we provide to you. We may need to share part of your health information with our billing department, your insurance company, collection agencies or attorneys assisting us with collections, and others who are responsible for your bill, such as a spouse, as necessary for us to collect payment. For example, we may give information about a dental procedure that you had to your dental insurance company so it will pay us or reimburse you for your dental procedure.

Health Care Operations

We may use and disclose health information in connection with our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performances, conducting training programs, accreditation, certification, and licensing or credentialing activities.

To Your Family, Friend, and Other Persons Involved in Your Care

We may share with a family member, friend, or other person identified by you, your health information that is directly related to that person’s involvement in your care or your payment, or to notify such individuals of your location or general condition, but only if you agree that we may do so, or, based on our professional judgment, we determine that you would not object to the disclosure.

Use and Disclosure of Health Information Required by Law

We may use and disclose your health information when required by federal or state law; when required in court or administrative proceedings; for public health activities; to health oversight agencies; to coroners, medical examiners, and funeral directors; to the military; to federal officials for lawful intelligence and national security activities; to correctional institutions regarding inmates; to law enforcement officials; to report abuse, neglect, or domestic violence; to avert a serious threat to your health or safety or the health and safety of others; and as authorized by state workers’ compensation laws.

Marketing Health-Related Services

We will not use your health information for marketing communications without your written authorization.

Contacting You

We may use and disclose your health information to contact you about appointments and other matters, and to send you billing via mail or electronic billing statements. We may contact you by telephone, email, or mail. We may leave you messages at the telephone number you give us.

Your Authorization

As explained in this Notice, we may use and disclose your health information for treatment, payment, or health care operations; in certain situations, if you agree or object; as required by law; to contact you; and to send your health-related information, but we cannot use or disclose your health information for any other reason without your written authorization. You may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any uses or disclosures already made with your authorization while it was in effect.

Patient Rights

Right to See and Copy Your Health Information

You have the right to see or get copies of your health information, with limited exceptions. If we deny your request due to one of these exceptions, we will respond to you with the reason we cannot grant your request and describe any right you may have to request a review of your denial. You must make a written request for us to access your health information. Your written request must be signed and dated. We may charge you a fee for expenses such as copies, staff time, and postage. Instead of providing you with a copy of your health information, we may prepare a summary or an explanation of your health information for a fee, if you agree in advance to the forms and the fees of the summary or explanation.

Right to Accounting of Disclosures of Your Health Information

You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, and health care operations, and certain other activities for the last six years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a fee for responding to these additional requests. You must submit a written request that is signed and dated. Your request must be submitted to the Privacy Officer, 150 Sage Brush Trail, Ormond Beach, FL 32174.

Right to Request Restriction

You have the right to request that we place additional restrictions on our use or disclosure of your health information, including uses or disclosures for treatment, payment, and health care operations, and to family members, friends, or others involved in your care or payment for your care. You must submit a written request that is signed and dated to the Privacy Officer, 150 Sage Brush Trail, Ormond Beach, FL 32174. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in certain situations, such as to provide you with emergency treatment).

Right to Request Alternative Communication

You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. For example, you can ask that we only contact you at work, or only by mail. You must make your request in writing and your request must be signed and dated. Your request must specify the ways in which you wish to be contacted. You do not need to tell us the reason for your request. Your request must be submitted to the Privacy Officer, 150 Sage Brush Trail, Ormond Beach, FL 32174.

Right to Request Amendment

You have the right to request that we amend your health information. You must submit a written request that is signed and dated. Your request must explain why your health information should be amended. Your request must be submitted to the Privacy Officer, 150 Sage Brush Trail, Ormond Beach, FL 32174. If we deny your request, we will respond to you in writing with the reason we cannot grant your request and explain your options.

Right to Written Notice

If you receive this Notice on our website or by email, you are entitled to receive this Notice in written form.

Questions and Complaints

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, 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 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.

Privacy Officer

Should you wish to contact the Privacy Officer, you may do so at the address and telephone number below:

Privacy Officer
150 Sage Brush Trail
Ormond Beach, FL 32174