HIPAA Notice of Privacy Practices
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
(PATIENT COPY: PLEASE RETAIN FOR YOUR RECORDS; Reviewed January 2018)
Who Will Follow This Notice
This notice describes the privacy practices of Modern Dentistry, located in Brooklyn, New York. These privacy practices apply to our dental practice and to our staff, including our dentists,
hygienists and other health care professionals, and employees working at our offices. Some of our dentists are independent contractors and are not employees or agents.
Our Pledge Regarding Health Information
We understand that medical information about you and your health is personal. We are committed to protecting your health information. We create a record of the care and services you
receive at our offices. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated or
kept by our dentists, hygienists and other staff.
This notice will tell you about the ways we may use and disclose your health information. We also describe your rights and certain obligations we have concerning the use and disclosure of
your health information.
We are required by law to:
• Make sure that health information that identifies you is kept private;
• Give you this notice of our legal duties and privacy practices with respect to health information about you; and
• follow the terms of this notice that is currently in effect, as we may change it from time to time.
How We May Use and Disclose Your Health Information
The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures, we will explain what we mean and try to give some
examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment: We may use your health information to provide you with dental treatment or services. We may disclose health information about you to dentists, dental assistants, hygienists,
other dental office personnel or other health care providers who are involved in your treatment or care. For example, your dentist may need to disclose some of your health information to
order tests or lab work to be performed at an outside laboratory or other outside health care provider, or your dentist may need to disclose your health information to people outside the office
who may be involved in your dental or health care after you leave the dental office, such as family members, or clergy.
For Payment: We may use and disclose health information about your treatment and services to bill and collect from you, your insurance company or a third party payer. For example, we may
need to give your dental/health insurance plan information so that it will pay us or reimburse you for dental services. We may also tell your health insurance plan about a treatment you are
going to receive to determine whether your plan will cover it.
For Health Care Operations: We may use and disclose your health information for office operations. These uses and disclosures are necessary to run our dental office and make sure that all of
our patients receive quality care. For example, we may use your health information to review our treatment and services and to evaluate the performance of our staff in caring for you. Some
of these reviews may be conducted by independent dentists who are members of our staff, but are not employees of the office. We may also combine health information about many of our
patients to decide what additional services we should offer and what services are not needed. We may also disclose information to dentists, hygienists, dental assistants and other office
personnel for review and learning purposes. We may also combine the health information we have with health information from other dental practices to see where we can make
improvements. We may remove information that identifies you from this set of health information to protect your privacy.
Appointment Reminders: We may use and disclose health information to contact you as a reminder that you have an appointment for treatment at our office.
Treatment Alternatives: We may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services: We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care: We may disclose your health information to a member of your family, your friend or another individual who is directly involved in
your care and the disclosure is necessary for your welfare. The practice will limit the health information disclosed to the family member, friend or other individual to health-related signs and
symptoms and to information designed to help you deal with your condition or treatment, including setting and changing appointments, receiving instructions for post-visit care or picking up
treatment-related items. We may also disclose a limited amount of your health information to locate you or to locate or notify your family member or friend. We may also give information to
someone who helps pay for your care. We will not make these disclosures to your friends and family if you tell us not to.
Research. Under certain circumstances, we may use and disclose health information about you for research purposes. We generally will obtain your written authorization to use your medical
information for research purposes. There may be limited circumstances when access to your information for research purposes may be allowed without your specific consent.
Business Associates: There are some services that we provide through contracts with business associates. For example, we use an outside copy service if needed to make copies of your x-rays.
When these services are contracted, we may disclose your health care information to our business associate so that the associate can perform the job we have asked the associate to do. To
protect your health information, we require the business associate to safeguard the privacy of your information.
As Required by Law: We will disclose health information about you when required to do so by federal, state or local law.
To Avoid a Serious Threat to Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and
safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
Military and Veterans: If you are a member of the armed forces, we may release health information about you as required by military command authorities.
Workers’ Compensation: We may release your health information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness. Your
written authorization to this release is required, however, if you do not consent to a release of information, your workers’ compensation benefits may be denied and you will be responsible for
the costs of your dental care.
Public Health Risks: We may disclose your health information for public health activities. These activities generally include the following:
• prevention or control of disease, injury or disability,
• reporting births and deaths,
• reporting abuse or neglect of children, elders and dependent adults,
• reporting reactions to medications or problems with products,
• notifying people of recalls of products they may be using or
• notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits,
investigations inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute we may disclose health information about you in response to a court or administrative order. We may also disclose health
information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the
request (which may include written notice to you) or to obtain an order protecting the information requested.
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Law Enforcement: We may release health information if asked to do so by a law enforcement official:
• In response to a court order, subpoena, warrant, summons or similar process,
• To identify or locate a suspect, fugitive, material witness or missing person,
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the persons’ agreement,
• About a death we believe may be the result of criminal conduct,
• About criminal conduct at the hospital and
• In emergency circumstances to report a crime, the location of the crime or victims or the identity, description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors: We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person
or determine the cause of death. We may also release health information about patients of the hospital to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities: We may release health information about you to authorized federal officials for intelligence, counter intelligence, and other national security
activities authorized by law.
Protective Services for the President and Others: We may disclose health information about you to authorized federal officials so they may provide protection to the President, other
authorized persons or foreign heads of state or conduct special investigations.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law
enforcement official if the release would be necessary for the institution to provide you with health care, to protect your health and safety and the health and safety of others or for the safety
and security of the correctional institution.
Permission from you: Other uses and disclosures of health information not covered in the above categories will be made only with your permission. You may give permission with a written
consent or authorization. If you provide us permission to use or disclose health information about you, you may revoke that permission at any time orally or in writing. If you revoke your
permission, we will no longer use or disclose health information about you to the extent your permission is needed for the use or disclosure. You understand that we are unable to take back
any disclosures we have already made with your permission and that we are required to retain our records of the care that we provide to you.
Your Health Information Rights
You have the following rights concerning health information we maintain about you:
Right to Inspect and Copy your Health Information: You have the right to inspect and copy your health information and to receive a written summary or explanation of your health information
if you make a request in writing by completing our records authorization form and you will be provided the information and copy of records within 72 hours after the administrative fee and
authorization form are completed. If you want to inspect, copy or receive this information, please contact the privacy officer listed at the end of this notice to obtain and complete the required
form. If you request a copy of your health information, we will charge you a fee for the costs of copying, mailing, compiling and/or printing your request or of preparing a written summary or
explanation, as well as for administrative fee that will cover labor costs. We may deny your request in certain very limited circumstances. If you are denied access to health information, you
may request that the denial be reviewed. Another licensed health care professional chosen by the office will review your request and denial. The person conducting the review will not be the
person who denied your request. We will comply with the outcome of the review.
Right to Receive your Health Information in Electronic Form: If you make a request on or after February 17, 2010, for an electronic copy of health information that we maintain in electronic
form, we will provide the information in electronic form to you or directly to a third party of your choice. For providing an electronic copy of your health information, we will charge you our
labor costs in responding to your request.
Right to Ask for Changes in Health Information: If you feel that health information we have about you is incorrect or incomplete, you may ask us to change or add to the information. You have
the right to ask for a change or addition for as long as the information is kept by the office. You should contact the privacy officer listed at the end of this notice to get the form you will need to
ask for a change or addition. You must give us a reason for your request. We may deny your request for a change or addition to your health information if it is not in writing or does not include
an appropriate reason to support the request. In addition, we may deny your request if you ask us to change or add to information that:
• we did not create, unless the person or entity that created the information is no longer available to make the change or addition,
• is not part of the health information kept by the office,
• is not part of the information which you would be permitted to inspect and copy or
• is already accurate and complete.
Right to an Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of the disclosures we made of your health information except for: disclosures
made to carry out treatment, payment or health care operations, disclosures to you, disclosures made pursuant to your authorizations, disclosures to persons involved in your care and certain
other special disclosures described in federal regulations. To ask for this list of disclosures, you should contact the privacy officer listed at the end of this notice to get the form you will need to
fill out for this purpose. Your request must state a time period, which may not be longer than six years before the date of the request. Your request should indicate in what form you want the
list (for example, on paper or electronically). The first list you request within a twelve-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.
Right to Request Restrictions: 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. Because any restrictions of
your information may hinder the quality of care provided by our facility, according to the law, we reserve the right to deny your request. We do not have to agree to the restrictions that you
request, but if we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you should contact the privacy officer at the address or number listed at the end of this notice to get the form you will need to fill out for this purpose. In your request,
you must tell us:
• what information you want to limit,
• whether you want to limit our use, disclosure or both and
• to whom you want the limits to apply (for example, your spouse, your children, your parents or other involved in your care).
To be binding on us, any agreement to comply with special restrictions must be in writing signed by the privacy officer for our office.
Right to Request Confidential Communications: You have the right to request that we communicate with you about your health information in a certain way or at a certain location. For
example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the privacy officer listed at the end of this
notice. 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.
Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this
notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, please contact the privacy officer listed at the end of this notice or ask any of our
Right to be Notified if Breach of Security: You have the right to be notified if there is a breach of security with respect to your protected health information. In the event of such a breach, we
will notify you directly in writing or, if your contact information is out of date, we will take steps to notify you by other means, such as a posting to our web site or notices in print or broadcast
Changes to this Notice
We reserve the right to change this notice and the revised or changed notice will be effective for health information we already have about you as well as any information we receive in the
future. The current notice will be posted in our dental offices and will include the effective date.
If you believe your privacy rights have been violated, you may file a complaint with our dental office or with the Secretary of the Department of Health and Human Services. To file a complaint,
contact the privacy officer listed at the end of this notice or ask any of our staff members. All complaints must be submitted in writing. You will not be penalized for filing a complaint.