- To other health care providers (i.e., your general dentist, oral surgeon, etc.) in connection with our
rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc.);
- To third party payers or spouses (i.e., insurance companies, employers with direct reimbursement,
administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to
determine benefits, dates of payment, etc.);
- To certifying, licensing and accrediting bodies (i.e., the American Board of Orthodontics, state dental
boards, etc.) in connection with obtaining certification, licensure or accreditation;
- Internally, to all staff members who have any role in your treatment;
- To other patients and third parties who may see or overhear incidental disclosures about your treatment,
- To your family and close friends involved in your treatment; and/or,
- We may contact you to provide appointment reminders or information about treatment alternatives or other
health-related benefits and services that may be of interest to you.
- Request restrictions on the use and disclosure of your protected health information
- Request confidential communication of your protected health information;
- Inspect and obtain copies of your protected health information through asking us;
- Amend or modify your protected health information in certain circumstances;
- Receive an accounting of certain disclosures made by us of your protected health information; and,
- You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with
us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States
Secretary of Health and Human Services (which must be filed within 180 days of the violation).
- By law, to maintain the privacy of protected health information and to provide you with this notice setting
forth our legal duties and privacy practices with respect to such information;
- To abide by the terms of our Privacy Notice that is currently in effect;
- To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions
effective for all protected health information maintained by us, and that if we do so, we will provide you
with a copy of the revised Privacy Notice.
- Amend your protected health information if, for example, it is accurate and complete;
- Provide an atmosphere that is totally free of the possibility that your protected health information may be
incidentally overheard by other patients and third parties.
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION