Hipaa Notice Of Privacy Practices (Page 2 of 3) in pdf

You have the right to request a restriction of your protected health information.

This means you may ask us not to

use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also

request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for

notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction

requested and to whom you want the restriction to apply.

Your dentist is not required to agree to a restriction that you may request. If your dentist believes it is in your best interest

to permit use and disclosure of PHI, your PHI will not be restricted. You then have the right to use another Healthcare

Professional.

You have the right to request to receive a copy of confidential communications from us by alternative means or

at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if

you have agreed to accept this notice alternatively, i.e. electronically.

You may have the right to have your dentist amend your protected health information. If we deny your request for

amendment, you have the right to file a statement of disagreement with us. In response to this request, we may prepare a

rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health

information.

4. As described in The Breach Notification Rule that is part of the HITECH Act of 2009, our office will notify all

responsible parties of any breach of unsecured protected health information.

5. We reserve the right to change the terms of this notice and will inform you at your next dental appointment of any

changes. You then have the right to object or withdraw as provided in this notice.

6. Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy

rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint.

We will not retaliate against you for filing a complaint.

8. How to Contact Us/Our Privacy Official

If you have any questions or would like further information about this Notice, you can either write to or call the Privacy

Official for our Dental Practice:

Dental Practice Name

All Grins 4 Kids

Privacy Official for Dental Practice:

Joy Warren

Dental Practice mailing address

317 Tamarack Lane

Shiloh, IL 62269

Dental Practice email address

Dental Practice phone number:

618-628-4400

This notice was published and becomes effective on/or befor e April 14.2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy

practices with respect to protected health information. If you have any objections to this form, please ask to speak with our

HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Hipaa Notice Of Privacy Practices Page 2