Notice of Privacy Practices

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Your information. Your rights. Our responsibilities.

This notice explains how Smiles One Family Dentistry may use and disclose your protected health information, the rights you have regarding that information, and our responsibilities to protect it. Health information includes information about your health, treatment, and payment for care that can identify you.

Your rights

To exercise these rights, contact our Privacy Officer using the information at the end of this notice. We may ask for a written request or identity verification.

Inspect and obtain a copy of your records

You may ask to see or receive an electronic or paper copy of your medical and billing records and other health information we maintain about you. We will provide a copy or summary, usually within 30 days. We may charge a reasonable, cost-based fee as permitted by law.

Request an amendment

You may ask us to correct information you believe is incorrect or incomplete. We may deny the request in certain circumstances, but we will explain the reason in writing, generally within 60 days. You may submit a statement of disagreement if we deny your request.

Request confidential communications

You may ask us to contact you in a specific way or send mail to a different address. We will accommodate reasonable requests.

Request restrictions

You may ask us not to use or disclose certain information for treatment, payment, or health care operations. We are not generally required to agree. If we agree, we will follow the restriction except when information is needed for emergency treatment or another exception applies.

If you pay in full out of pocket for a specific item or service, you may ask us not to disclose information about it to your health plan for payment or health care operations. We will agree unless a law requires disclosure.

Receive an accounting of certain disclosures

You may request a list of certain disclosures made during the six years before your request. It will not include certain disclosures, including those for treatment, payment, or health care operations. One accounting in a 12-month period is free; a reasonable cost-based fee may apply to another.

Receive a paper copy

You may request a paper copy at any time, even if you previously agreed to receive this notice electronically.

Choose someone to act for you

A legally authorized personal representative may exercise your rights. We will verify that authority before acting.

File a complaint

You may complain to Smiles One Family Dentistry using the contact information below. You may also complain to the U.S. Department of Health and Human Services Office for Civil Rights at hhs.gov/hipaa/filing-a-complaint, by calling 1-877-696-6775, or by writing to 200 Independence Avenue, S.W., Washington, D.C. 20201.

We will not retaliate against you for filing a complaint.

Your choices

You may tell us your preferences when we disclose relevant information to family, close friends, or others involved in your care or payment, and for disaster relief. If you cannot tell us your preference, we may disclose information when we believe it is in your best interest and the law permits. We may also disclose information to lessen a serious and imminent threat to health or safety.

Written authorization

We will not use or disclose health information for marketing, sell health information, or disclose most psychotherapy notes unless you give written authorization or a narrow legal exception applies. Other uses and disclosures not described in this notice require written authorization. You may revoke an authorization in writing at any time, but revocation does not undo actions already taken in reliance on it.

Fundraising

We may contact you about fundraising efforts as permitted by law. You may tell us not to contact you again for fundraising.

How we may use and disclose information

Treatment

We may use and disclose information to provide, coordinate, or manage dental care. Example: We may share an X-ray or treatment information with a dental specialist, laboratory, pharmacy, or another professional involved in your care.

Payment

We may use and disclose information to bill and obtain payment. Example: We may submit examination, diagnosis, or treatment information to your dental plan so it can determine benefits and process a claim.

Health care operations

We may use and disclose information to run the practice, improve care, train our workforce, conduct quality reviews, perform audits, and complete other lawful operations. Example: We may review records to evaluate care, manage scheduling, or assess team and business-associate performance.

Business associates

We may disclose information to service providers that perform functions for us. When required, they must agree in writing to protect it.

Reminders and treatment alternatives

We may contact you about appointments, follow-up care, treatment alternatives, or health-related benefits and services as permitted by law.

Public health and safety

We may disclose information for lawful public-health and safety activities, including disease prevention, product problems, suspected abuse or neglect, and serious threats to health or safety.

Health oversight and research

We may disclose information for authorized audits, investigations, inspections, licensing, credentialing, disciplinary activities, or approved research when applicable requirements are met.

Required by law

We will disclose information when federal, state, or local law requires it, including to HHS when it reviews our compliance. We will limit the disclosure to what the law requires.

Workers' compensation, law enforcement, and government functions

We may use or disclose information for workers' compensation, certain law-enforcement purposes, lawful custody situations, and special government functions when legal requirements are met.

Legal proceedings

We may disclose information in response to a court or administrative order or, when requirements are met, a subpoena, discovery request, or other lawful process.

After death and organ donation

We may disclose information to coroners, medical examiners, funeral directors, and organ-procurement organizations as permitted or required.

Substance use disorder records

To the extent we receive or maintain records protected by 42 CFR Part 2, those records and testimony describing their contents will not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless you give written consent or a court issues an order after the notice and opportunity-to-be-heard requirements of Part 2 are satisfied. A court order must be accompanied by a subpoena or other legal requirement compelling disclosure before the record is used or disclosed.

Our responsibilities

• We are required by law to maintain the privacy and security of protected health information.
• We must provide you with this notice of our legal duties and privacy practices.
• We must follow the notice currently in effect.
• We will notify affected patients after a breach of unsecured protected health information when required.
• We will not use or disclose information outside this notice unless you authorize it in writing or the use or disclosure is permitted or required by law.

Changes to this notice

We may change this notice and make the revised terms effective for all information we maintain, including information created or received earlier. A revised notice will be available at our office, upon request, and on our website, and will state its effective date.

State and other protections

When Pennsylvania or another applicable law provides greater privacy protection or stricter limits than HIPAA, we will follow the more protective law.

Questions and complaints