Smile Line Dentistry Notice of Privacy Practices

Your Information. Your Rights. Our Responsibilities.

This notice of our privacy practices describes how your protected health information may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

You have the right to:

Get a copy of your record.
Get a copy of this privacy notice.
Correct information in your record.
Choose someone to act for you.
Request confidential communication.
Ask us to limit the information we share.
Get a list of those with whom we have shared your information.
File a complaint if you believe your privacy rights have been violated.

Your Choices

You have some choices in the way that we use and share information as we:

Tell family and friends about your condition.
Provide disaster relief.
Market our services and sell your information.
Raise funds (delete if your practice is not a nonprofit clinic).

Our Uses and Disclosures

We may use and share your information as we:

Treat you.
Bill for your services.
Run our organization.
Help with public health and safety issues.
Do research.
Respond to organ and tissue donation requests.
Work with a medical examiner or funeral director.
Address workers’ compensation, law enforcement, and other government requests.
Respond to lawsuits and legal actions.
Comply with the law.

Smile Line Dentistry complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.

English: Our dental practice will provide language assistance services free-of-charge to individuals who do not speak English well enough to discuss the dental care we are providing.

Spanish: Nuestro consultorio dental les proporcionará servicios de asistencia lingüística gratuitos a los individuos que no hablen inglés con suficiente fluidez para discutir la atención dental que proporcionamos.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your record

You can ask to see or get an electronic or paper copy of your record. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 15 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your record

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

You can ask for a list (accounting) of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

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 health information.
We will verify the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting us using the information below.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting Health and Human Services HIPAA.
We will not retaliate against you for filing a complaint.

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, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in your care.
Share information in a disaster relief situation.

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

In these cases we never share your information unless you give us written permission:

Marketing purposes.
Sale of your information, except as part of a practice sale or merger.
Substance use disorder treatment information in your record.

In the case of fundraising for our nonprofit organization, we may contact you for fundraising efforts, but you can tell us not to contact you again. (Delete if statement is not applicable.)

Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways:

Treat you We can use your health information and share it with other professionals who are treating you. The dentist may refer you to another dentist who specializes in treating certain types of cases, or may consult with your physician when you are scheduled for dental surgery.

Run our organization We can use and share your health information to run our practice, improve your care, and contact you when necessary. For example, we may use a third-party service or artificial intelligence system to manage appointment reminders, patient communications and our schedule, and to assist with documentation. When we do so, we have agreements that reinforce that they are required to comply with privacy and security laws.

Bill for your services We can use and share your health information to bill and get payment from health plans or other entities. Example: We give necessary information about you to your health insurance plan so it will pay for the services we provide you.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We must meet specified conditions in the law before we can share your information for these purposes. For more information see: Your Rights Under HIPAA

Help with public health and safety issues

We can share health information about you for certain situations such as:

Preventing disease.
Helping with product recalls.
Reporting adverse reactions to medications.
Reporting suspected abuse, neglect, or domestic violence.
Preventing or reducing a serious threat to anyone’s health or safety.

Do research We can use or share your information for health research.

Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

Work with a medical examiner or funeral director We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

For workers’ compensation claims.
For law enforcement purposes or with a law enforcement official.
With health oversight agencies for activities authorized by law.
For special government functions such as military and national security.

Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.
We will not send you unsecured emails containing your protected health information without obtaining your informed consent.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
We are required to comply with California law which places further restrictions on the use and disclosure of your information. For example, we may not share without your written consent any information we hold regarding treatment for mental health or substance abuse, abortion, contraception or gender-affirming care.

For more information see: Notice of Privacy Practices

Changes to the Terms of 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 upon request, in our office and on our website.

Other Instructions for Notice

Insert any special notes that apply to your entity’s practices such as “we never market or sell personal information.”
If your dental practice is part of an OHCA (organized health care arrangement) that has agreed to a joint notice, use this space to inform your patients of how you share information within the OHCA (such as for treatment, payment, and operations related to the OHCA). Also, describe the other entities covered by this notice and their service locations. For example, “This notice applies to Grace Community Hospitals and Emergency Services Incorporated which operate the emergency services within all Grace hospitals in the greater Dayton area.”

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us.
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 response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may send a written complaint to our office or to the U.S. Department of Health and Human Services, Office of Civil Rights, 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting Health and Human Services. We will not retaliate against you for filing a complaint.

Smile Line Dentistry complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.