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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU/YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. ('You' and 'your child' are interchangeable throughout this document). We understand that medical information about your child and their health is personal "Protected Health Information" ("PHI") and we are committed to protecting their medical information. PHI includes individually identifiable information about your child's past, present, or future health or condition, the provision of health care to them, or payment for such health care.

We use and disclose PHI about your child for treatment, payment, and health care operations.

Treatment: We may disclose PHI to your child's insurance provider, our dentist(s), and other dental care providers for treatment purposes. For example, your child's dentist may wish to provide a dental service to your child but first seeks information from your child's insurance provider as to whether the service has been previously provided.

Payment: We disclose your child's PHI in order to fulfill our duty to check your child's coverage, determine their benefits, and secure payment for services provided to them. For example, we use your child's PHI in order to request process of their claims by their insurance provider.

Health Care Operations: We disclose your child's PHI as a part of certain operations, such as quality improvement. For example, we may use your child's PHI to evaluate the quality of dental services that were performed. We may be asked by the sponsor of your child's health plan to provide their PHI to the sponsor. If we are asked to do so, we intend to honor such requests unless we are prohibited by law.

We may use or disclose your child's PHI without your authorization for several other reasons. Subject to certain requirements, we may give out PHI without your authorization for public health purposes, auditing purposes, research studies, and emergencies. We provide PHI when otherwise required by law, such as for law enforcement in specific circumstances, or for judicial or administrative proceedings. In any other situation, we will ask for your written authorization before using or disclosing your child's PHI. If you choose to sign an authorization to allow disclosure of your child's PHI, you can later revoke that authorization to stop any future uses and disclosures (other than for treatment, payment, and health care operations).

We may change our policies at any time. Before we make a significant change in our policies, we will change our notice and send the new notice to you. You can also request a copy of our notice at any time.

Individual Rights

In most cases, you have the right to view or get a copy of your child's PHI. You also have the right to receive a list of instances where we have disclosed your child's PHI without your written authorization for reasons other than treatment, payment, or health care operations. If you believe that information in your child's record is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information. You may request in writing that we not use or disclose your child's PHI for treatment, payment, and health care operations except when specifically authorized by you, when required by law, or in emergency circumstances. We will consider your request but are not legally required to accept it. You also have the right to receive confidential communications of PHI by alternative means or at alternative locations if you clearly state that disclosure of all or part of your child's PHI could endanger you.

Complaints

If you are concerned that we have violated your child's privacy rights, or you disagree with a decision we have made about access to your child's records, you may contact the address listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. Customer Service can provide you with the appropriate address upon request.

Our Legal Duty

We are required by law to protect the privacy of your and your child's information, provide this notice about our information practices, and follow the information practices that are described in this notice. If you wish to inspect your child's records, receive a listing of disclosures, or correct or add to the information in your child's record, or if you have any questions, complaints, or concerns, please contact our office.

In Our Office

We do send thank you cards to our referral sources following new patient exams. These cards do have the name of the patient that was referred to our office. If you do not want to have your child's name stated in the thank you card, please inform our office of this at your child's initial visit. We also reward patients with no cavities by having a drawing at the end of each month and we post the winner in the office. If you do not want to have your child's name added to this drawing, please inform our office. We are actively doing things in our office to acknowledge and reward our patients, and these things may include acknowledging patients by name. If you do not want your child's name posted, printed, announced, or acknowledged, inform our office.

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