Purpose 

We respect your privacy. We are also legally required to maintain the privacy of your protected health information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA). 

As part of our commitment and legal compliance, we are providing you with this Notice of Privacy Practices (Notice). This Notice describes: 

• Our legal duties and privacy practices regarding your PHI, including our duty to notify you following a data breach of your unsecured PHI.  

• Our permitted uses and disclosures of your PHI. 

• Your rights regarding your PHI. 

PHI Defined 

Your PHI: 

• Is health information about you: 

• which someone may use to identify you; and 

• which we keep or transmit in electronic, oral, or written form.  

• Includes information such as your: 

• name; 

• contact information; 

• past, present, or future physical or mental health or medical conditions;  

• payment for health care products or services; or 

• prescriptions. 

Scope 

We create a record of the care and health services you receive, to provide your care, and to comply with certain legal requirements. This Notice applies to all the PHI that we generate.  

We and our employees and other workforce members follow the duties and privacy practices that this Notice describes and any changes once they take effect.  

Changes to this Notice  

We can change the terms of this Notice, and the changes will apply to all information we have about you. The new notice will be available on request, in our office, and on our website. 

Data Breach Notification  

We will promptly notify you if a data breach occurs that may have compromised the privacy or security of your PHI. We will notify you within the legally required time frame. Most of the time, we will notify you in writing, by first-class mail, or we may email you if you have provided us with your current email address and you have previously agreed to receive notices electronically.  

Your Rights  

As a patient, you have the rights regarding medical information that we maintain about you: 

1. Right to Inspect and Copy: You have the right to inspect and obtain a copy of your paper or electronic protected health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. 

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. If the Plans do not maintain the health information, but know where it is maintained, you will be informed of where to direct your request. 

1. Right to Amend Your Records: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for your benefit plan. 

You also must provide a reason that supports your request. 

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend any of the following information: 

• Information that is not part of the health information kept by or for your benefit plan. 

• Information that was not created by us, unless the person or entity that created the information is no longer available to make the amendment. 

• Information that is not part of the information which you would be permitted to inspect and copy. 

• Information that is accurate and complete. 

1. Right to Request Confidential Communications: You have the right to request that we communicate with you about health related matters in a certain way or at a certain location. For example, you can ask that we only contact you at work, by phone, or by mail. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. 

1. Right to Request Restrictions on Use or Disclosure: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose information about a procedure that you had. 

We are not required to agree to your request. If your benefit plan does agree to a request, a restriction may later be terminated by your written request, by agreement between you and your benefit plan, or unilaterally by your benefit plan for health information created or received after your benefit plan has notified you that they have removed the restrictions and for emergency treatment. 

To request restrictions, you must make your request in writing and must tell us the following information: 

• What information you want to limit. 

• Whether you want to limit our use, disclosure, or both. 

• To whom you want the limits to apply (for example, disclosures to your spouse). 

We will comply with any restriction request if: (1) except as otherwise required by law, the disclosure is to your benefit plan for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment); and (2) the protected health information pertains solely to a health care item or service for which the health care provider involved has been paid out-of-pocket in full. 

1. Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures” (that is, a list of certain disclosures the Plans have made of your health information). Generally, you may receive an accounting of disclosures if the disclosure is required by law, made in connection with public health activities, or in situations similar to those listed herein as permitted disclosures. You do not have a right to an accounting of disclosures where such disclosure was made: 

• For treatment, payment, or health care operations. 

• To you about your own health information. 

• Incidental to other permitted disclosures. 

• Where authorization was provided. 

• To family or friends involved in your care (where disclosure is permitted without authorization). 

• For national security or intelligence purposes or to correctional institutions or law enforcement officials in certain circumstances. 

• As part of a limited data set where the information disclosed excludes identifying information. 

To request this list or accounting of disclosures, you must submit your request, which shall state a time period that is not longer than six years ago. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. 

Notwithstanding the foregoing, you may request an accounting of disclosures of any “electronic health record” (that is, an electronic record of health-related information about you that is created, gathered, managed, and consulted by authorized health care providers and staff). To do so, however, you must submit your request and state a time period, which may be no longer than three years prior to the date on which the accounting is requested. In the case of any electronic health record created on your behalf, this paragraph shall apply to disclosures made on or after the date we acquired the electronic health record. 

1. Choose someone to act for you: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your PHI. 

1. Request confidential communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or at a specific address. For these requests:  

• you must specify how or where you wish to be contacted; and 

• we will accommodate reasonable requests. 

1. Right to Receive a Copy of this Notice: You have the right to request a copy of this notice in print or electronic form at any time. 

For a detailed explanation of your rights, visit the HHS Consumer Rights Page. 

Your Choices 

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, please contact us at <contact@gps.dental> and we will make reasonable efforts to follow your instructions. 

In these cases, you have both the right and choice to tell us whether to: 

• Share information, such as your PHI, general condition, or location, with your family, close friends, or others involved in your care. 

• Share information in a disaster relief situation, such as to a relief organization to assist with locating or notifying your family, close friends, or others involved in your care. 

If you are not able to tell us your preference, for example if you are unconscious, we may share your information if we believe it is in your best interest, according to our best judgment. We may also share your information when needed to lessen a serious and imminent threat to health or safety.