Carter Family Dentistry
Notice of Privacy Policy
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
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that health providers keep your medical
and dental information private. The HIPAA Privacy Rule states that health providers must also post in a clear and
prominent location, and provide patients with a written Notice of Privacy Policy.
The privacy practices described are currently in effect. We reserve the right to change our privacy practices, and the terms
of this Notice at any time, provided such changes are permitted by law. If changes are made, a new Notice of Privacy
policy will be displayed in our office and provided to patients. You may request a copy of our Notice at any time. Additional
information may be obtained from the HIPAA Coordinator listed in our written HIPAA plan.
USES AND DISCLOSURES OF HEALTH INFORMATION
The following describes how information about you may be used in this dental office:
● Treatment Services: We may use or disclose your health information to all of our staff members, other dentists,
your physicians, and/or other health care providers taking care of you.
● Payment and Health Care Operations: We may use or disclose your health information to obtain payment for
services we provide to you, to participate in quality assurance, disease management, training, licensing, and
certification programs. Upon your written request, we will not disclose to your health insurer any services paid
by you out of pocket.
● Marketing/Fundraising: We will not use your health information for marketing or fundraising purposes without
your written consent. You can opt out of receiving information about our marketing or fundraisers. We will not
sell your health information without your explicit authorization.
● Appointment Reminders: We may use or disclose your health information to provide you with appointment
reminders such as voicemail messages, text messages, emails, postcards, or letters.
● Legal Requirements: We may use or disclose your health information when required to do so by law.
● Abuse or Neglect: If abuse or neglect is reasonably suspected, we may use or disclose your health information
to the appropriate governmental authorities.
● National Security: When required, we may disclose military personnel health information to the Armed Forces.
Information may be given to authorized federal offices when required for intelligence and national security
activities. Health information for inmates in custody of law enforcement may be provided to correctional
institutes.
● Family Members, Friends, and Others Involved in Care: At your request, we may disclose your health
information to a family member or other person if necessary to assist with your treatment and/or payment for
services. Based on our judgment and as per 164.522(a) of HIPAA we may disclose your information to these
persons in the event of an emergency situation. We also may make information available so that another person
may pick up filled prescriptions, medical supplies, records, or x-rays for you. Your information may be disclosed
to assist in notifying a family member, caregiver, or personal representative of your location, condition, or death.
● Business Associates: Some services in our organization are provided through contacts with business
associates. Examples include practice management software representatives, accountants, answering service
personnel, etc. When these services are contracted, we may disclose your health information to our business
associates so that they can perform the job we have asked them to do and bill you or your third-party payer for
services rendered. All of our business associates are required to safeguard your information and to follow
HIPAA Privacy Rules.
● Workers' Compensation: We may release medical information about you for workers' compensation or similar
programs. These programs provide benefits for work-related injuries or illnesses.
● Research: We may use or disclose medical information to researchers when an institution's review board or
special privacy board has reviewed the proposed study and established protocols to ensure the privacy of the
health information used in their research and determined that the researcher does not need to obtain your
authorization prior to using your medical information for research purposes.
● Public Health Activities: We may use or disclose your health information for public health activities, to include
the following: to prevent or control disease, injury, or disability; to report reactions with medications or problems
with products, to notify people of recalls of products they may be using; to notify a person who may have been
exposed to a disease or who may be at risk for contracting or spreading a disease of condition; to notify the
proper government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence
(when required by law).
● Other Authorizations: In addition to our use of your health information for treatment, payment, or healthcare
operations, you may give us written authorization to use your health information or to disclose it to anyone for
any purpose. If you give us authorization, you may revoke it at any time. Your revocation will not affect any use
or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization,
we cannot use or disclose your health information for any reason except those described in this Notice.
● Breach Notification: We will notify you any time your PHI may have been compromised through unauthorized
acquisition, use or disclosure.
PATIENT RIGHTS
● Access: You have the right to look at or get copies of your health information, with limited exceptions. You may
request that we provide copies in a format other than photocopies. We will use the format you request unless
we cannot practicably do so. You must make a request in writing to obtain access to your health information.
● Accounting of Disclosures: 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, healthcare
operations and certain other activities, for the last 6 years. 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 these additional requests.
● Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your
health information. We will keep your information confidential from your health plans if you pay cash, at your
request. In some instances, we may not be required to agree to these additional restrictions, but if we do, we
will abide by our agreement (except in an emergency).
● Alternative Communication: You have the right to request that we communicate with you about your health
information by alternative means or to alternative locations. (You must make your request in writing.) Your
request must specify the alternative means or location, and provide satisfactory explanation how payments will
be handled under the alternative means or location you request.
● Amendment: You have the right to request that we amend your health information. (Your request must be in
writing, and must explain the reason for the amendment.) We may deny your request under certain
circumstances.
QUESTIONS AND COMPLAINTS
If you want more information about our Privacy Policy or have questions or concerns, please contact us. If you have
concerns relating to a perceived violation of your privacy rights, to access to your health information, to amending or
restricting the use or disclosure of your health information, or to requesting alternative means of communication, you may
contact us using the contact information listed at the end of this Notice. You also may submit a written complaint to the
Department of Health and Human Services (HHS). We will provide you with the HHS address 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 HHS.