Your Information. Your Rights. Our Responsibilities.
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
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 medical record: (1) You can ask to see or get an electronic or paper copy of
your medical record and other health information we have about you. Ask us how to do this. (2) We will provide a copy
or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record: (1) You can ask us to correct health information about you that you think is
incorrect or incomplete. Ask us how to do this. (2) We may say “no” to your request, but we’ll tell you why in writing
within 60 days.
Ask us to limit what we use or share: (1) You can ask us not to use or share certain health information for treatment,
payment, or our operations. (2) We are not required to agree to your request, and we may say “no” if it would affect
your care. (3) 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. (4) We will say “yes” unless a law
requires us to share that information.
Get a list of those with whom we’ve shared information: (1) You can ask for a list (accounting) of the times we’ve
shared your health information for six years prior to the date you ask, who we shared it with, and why. (2) 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: (1) 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: (1) 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. (2) We will make sure
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: (1) You can complain if you feel we have violated your rights by
contacting us using the information on the back page. (2) 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 www.hhs.gov/ocr/privacy/hipaa/ complaints/. (3) We will not retaliate against
you for filing a complaint.
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: (1) Share information with your family, close friends, or
others involved in your care (2) Share information in a disaster relief situation (3) Include your information in a hospital
directory. 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: (1) Marketing purposes (before
and after pictures (2) Sale of your information (3) Most sharing of psychotherapy notes
In the case of fundraising: (1) We may contact you for fundraising efforts, but you can tell us not to contact you again.
OUR USES AND DISCLOSURES
How do we typically use or share your health information? We typically use or share your health information in the
Treat you: (1) We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization: (1) We can use and share your health information to run our practice, improve your care, and
contact you when necessary. Example: We use health information about you to manage your treatment and services.
Bill for your services: (1) We can use and share your health information to bill and get payment from health plans or
other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
Appointment Reminders: (1) We may use or disclose your health information to provide you with appointment
reminders (such as voicemail messages, postcards, or letters).
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 many
conditions in the law before we can share your information for these purposes. For more information see:
Help with public health and safety issues: (1) 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 (1) We can use or share your information for health research.
Comply with the law: (1) 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’re complying with federal privacy law.
Respond to organ and tissue donation requests: (1) We can share health information about you with organ
Work with a medical examiner or funeral director: (1) 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: (1) 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, national security, and presidential protective services.
Respond to lawsuits and legal actions: (1) We can share health information about you in response to a court or
administrative order, or in response to a subpoena.
(1) We are required by law to maintain the privacy and security of your protected health information. (2) We will let you
know promptly if a breach occurs that may have compromised the privacy or security of your information. (3) We must
follow the duties and privacy practices described in this notice and give you a copy of it. (4) 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.
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.
Village Periodontics and Dental Implant Center - Website: villageperiodontics.com
Address: 12161 County Road 103, Oxford, FL 34484 Phone: (352) 259-6799