HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Fort Worth Dental is committed to protecting the privacy of your health information. This Notice of Privacy Practices ("Notice") describes how we may use and disclose your protected health information ("PHI") to carry out treatment, payment, or health care operations, and for other purposes that are permitted or required by law.

Our Legal Duty

We are required by applicable federal and state law to maintain the privacy of your PHI. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your PHI. We must follow the privacy practices that are described in this Notice while it is in effect.

Uses and Disclosures of Protected Health Information

Treatment

We may use and disclose your PHI to provide, coordinate, or manage your dental care and any related services. For example, we may disclose your PHI to a specialist to whom we refer you for treatment.

Payment

We may use and disclose your PHI to obtain payment for services we provide to you. For example, we may send claims to your dental plan or insurance company.

Health Care Operations

We may use and disclose your PHI for our health care operations. These uses and disclosures are necessary to run the practice and make sure that all of our patients receive quality care.

Your Rights Regarding Your PHI

• Right to Access: You have the right to look at or get copies of your PHI.
• Right to Amend: You have the right to request that we amend your PHI if you believe it is incorrect or incomplete.
• Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your PHI.
• Right to Request Confidential Communications: You have the right to request that we communicate with you about your PHI in a certain way or at a certain location.
• Right to an Accounting of Disclosures: You have the right to receive a list of disclosures we have made of your PHI.
• Right to a Paper Copy of This Notice: You have the right to receive a paper copy of this Notice at any time.

Changes to This Notice

We reserve the right to change the terms of this Notice at any time. Any new Notice will be effective for all PHI that we maintain at that time. We will post the current Notice in our office and on our website.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact our Privacy Officer at:

Contact Information

If you have any questions about this Notice or our privacy practices, please contact our Privacy Officer at the address or phone number listed above.