Patient Rights and Privacy Policy

You have the right to look at or get copies of your health information, with limited exceptions.  You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so.  (You must make a request in writing to obtain access to your health information).  We may charge you a reasonable cost-based fee for expenses such as copies and staff time.  If you request an alternative format, we will charge a cost-based fee for providing your health information in that format.

Disclosure Accounting:
You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, but not before April 14, 2003. If you request this accounting more than once ina12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

You have the right to request that we place additional restrictions on our use or disclosure of your health information.  We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication:
You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing.}  Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

You have the right to request that we amend your health information (Your request must be in writing, and it must explanin why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice:
If you receive this Notice on our Website or by Email, you are entitled to receive this Notice in written form.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us at the address or phone number provided on this website.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in reponse to a request you made to amend or restrict the use of disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed on this website. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Copyright 2002, 2009 American Dental Association. All Rights Reserved.