Dental Registration And History Form (Page 7 of 7) in pdf

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible

victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the

extent necessary to avert a serious threat to your health or safety or the health or safety of others.

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 of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as

voicemail messages, postcards, or letters.)

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. 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.)

Disclosure Accounting: 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, but not

before April 14, 2003. 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.

Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information.

We are not 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 it must

explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail(e-mail), 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, or 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.

Contact Officer:

Hope Matthies

Telephone:

432-337-6165

Fax:

432-337-5204

E-Mail:

Address:

2455 E. 11

St., Odessa, TX 79761

Dental Registration And History Form Page 7

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