How we may use and disclose health information about you

We may use and disclose your health information fordifferent purposes, including treatment, payment, andhealth care operations. For each of these categories,we have provided a description and an example. Someinformation, such as HIV-related information, geneticinformation, alcohol and/or substance use disordertreatment records, and mental health records may beentitled to special confidentiality protections underapplicable state or federal law. We will abide by thesespecial protections as they pertain to applicablecases involving these types of records.

Treatment. We may use and disclose your healthinformation for your treatment. For example, wemay disclose your health information to a specialistproviding treatment to you.

Payment. We may use and disclose your healthinformation to obtain reimbursement for thetreatment and services you receive from us oranother entity involved with your care. Paymentactivities include billing, collections, claimsmanagement, and determinations of eligibility andcoverage to obtain payment from you, an insurancecompany, or another third party. For example,we may send claims to your dental health plancontaining certain health information.

Healthcare Operations. We may use anddisclose your health information in connectionwith our healthcare operations. For example,healthcare operations include quality assessmentand improvement activities, conducting trainingprograms, and licensing activities.

Individuals Involved in Your Care or Payment forYour Care. We may disclose your health informationto your family or friends or any other individualidentified by you when they participate in your careor in the payment for your care. Additionally, wemay disclose information about you to a patientrepresentative. If a person has the authority by lawto make health care decisions for you, we will treatthat patient representative the same way we wouldtreat you with respect to your health information.

Disaster Relief. We may use or disclose your healthinformation to assist in disaster relief efforts.

Required by Law. We may use or disclose your healthinformation when we are required to do so by law.

Public Health Activities. We may disclose your healthinformation for public health activities, includingdisclosures to:

• Prevent or control disease, injury or disability;
• Report child abuse or neglect;
• Report reactions to medications or problems withproducts or devices;
• Notify a person of a recall, repair, or replacementof products or devices;
• Notify a person who may have been exposed toa disease or condition; or
• Notify the appropriate government authority ifwe believe a patient has been the victim of abuse,neglect, or domestic violence.

National Security. We may disclose to military authoritiesthe health information of Armed Forces personnel undercertain circumstances. We may disclose to authorizedfederal officials health information required for lawfulintelligence, counterintelligence, and other national securityactivities. We may disclose to correctional institution or lawenforcement official having lawful custody the protectedhealth information of an inmate or patient.

Secretary of HHS. We will disclose your health informationto the Secretary of the U.S. Department of Health andHuman Services when required to investigate or determinecompliance with HIPAA.

Worker’s Compensation. We may disclose your PHI to theextent authorized by and to the extent necessary to complywith laws relating to worker’s compensation or other similarprograms established by law.

Law Enforcement. We may disclose your PHI for lawenforcement purposes as permitted by HIPAA, as requiredby law, or in response to a subpoena or court order.

Health Oversight Activities. We may disclose your PHI toan oversight agency for activities authorized by law. Theseoversight activities include audits, investigations, inspections,and credentialing, as necessary for licensure and for thegovernment to monitor the health care system, governmentprograms, and compliance with civil rights laws.

Judicial and Administrative Proceedings. If you areinvolved in a lawsuit or a dispute, we may disclose yourPHI in response to a court or administrative order. We mayalso disclose health information about you in response toa subpoena, discovery request, or other lawful processinstituted by someone else involved in the dispute, but onlyif efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an orderprotecting the information requested.

Research. We may disclose your PHI to researchers whentheir research has been approved by an institutional reviewboard or privacy board that has reviewed the researchproposal and established protocols to ensure the privacyof your information.

Coroners, Medical Examiners, and Funeral Directors.We may release your PHI to a coroner or medical examiner.This may be necessary, for example, to identify a deceasedperson or determine the cause of death. We may alsodisclose PHI to funeral directors consistent with applicablelaw to enable them to perform their duties.

Fundraising. We may contact you to provide you withinformation about our sponsored activities, includingfundraising programs, as permitted by applicable law.If you do not wish to receive such information from us,you may opt out of receiving the communications.

SUD Treatment Information. If we receive or maintainany information about you from a substance use disordertreatment program that is covered by 42 CFR Part 2 (a“Part 2 Program”) through a general consent you provide tothe Part 2 Program to use and disclose the Part 2 Programrecord for purposes of treatment, payment or health careoperations, we may use and disclose your Part 2 Programrecord for treatment, payment and health care operationspurposes as described in this Notice. If we receive or maintainyour Part 2 Program record through specific consent youprovide to us or another third party, we will use and discloseyour Part 2 Program record only as expressly permitted byyou in your consent as provided to us.

In no event will we use or disclose your Part 2 Programrecord, or testimony that describes the informationcontained in your Part 2 Program record, in any civil,criminal, administrative, or legislative proceedings by anyFederal, State, or local authority, against you, unlessauthorized by your consent or the order of a court afterit provides you notice of the court order.

Other Uses and Disclosures of PHI

Your authorization is required, with a few exceptions, fordisclosure of psychotherapy notes, use or disclosure of PHIfor marketing, and for the sale of PHI. We will also obtainyour written authorization before using or disclosing yourPHI for purposes other than those provided for in thisNotice (or as otherwise permitted or required by law).You may revoke an authorization in writing at any time.Upon receipt of the written revocation, we will stop usingor disclosing your PHI, except to the extent that we havealready acted in reliance on the authorization.

Your Health Information Rights

Access. You have the right to look at or get copies of yourhealth information, with limited exceptions. You must makethe request in writing. You may obtain a form to requestaccess by using the contact information listed at the endof this Notice. You may also request access by sending us aletter to the address at the end of this Notice. If you requestinformation that we maintain on paper, we may providephotocopies. If you request information that we maintainelectronically, you have the right to an electronic copy. Wewill use the form and format you request if readily producible.We will charge you a reasonable cost-based fee for the costof supplies and labor of copying, and for postage if you wantcopies mailed to you. Contact us using the information listed atthe end of this Notice for an explanation of our fee structure.

If you are denied a request for access, you have the rightto have the denial reviewed in accordance with therequirements of applicable law.

Disclosure Accounting. With the exception of certaindisclosures, you have the right to receive an accounting ofdisclosures of your health information in accordance withapplicable laws and regulations. To request an accountingof disclosures of your health information, you must submityour request in writing to the Privacy Official. If yourequest this accounting more than once in a 12-monthperiod, we may charge you a reasonable, cost-based feefor responding to the additional requests.Right to Request a Restriction. You have the r

Amendment. You have the right to request that we amendyour health information. Your request must be in writing,and it must explain why the information should be amended.We may deny your request under certain circumstances. If we agree to your request, we will amend your record(s)and notify you of such. If we deny your request for anamendment, we will provide you with a written explanationof why we denied it and explain your rights.

Right to Notification of a Breach. You will receivenotifications of breaches of your unsecured protectedhealth information as required by law.

Electronic Notice. You may receive a paper copy of thisNotice upon request, even if you have agreed to receivethis Notice electronically on our Web site or by electronicmail (e-mail).

Questions and Complaints

If you want more information about our privacy practicesor have questions or concerns, please contact us.

If you are concerned that we may have violated yourprivacy rights, or if you disagree with a decision we madeabout access to your health information or in response to arequest you made to amend or restrict the use or disclosureof your health information or to have us communicate withyou by alternative means or at alternative locations, youmay complain to us using the contact information listedat the end of this Notice. You also may submit a writtencomplaint to the U.S. Department of Health and HumanServices. We will provide you with the address to file yourcomplaint with the U.S. Department of Health and HumanServices upon request.

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

Privacy Official Name and Contact Information:

Guardian Dentistry Partners

Pesis Family Dental
29224 W 8 Mile Rd
Farmington Hills MI 48336-5500
248-478-1650
pesisd@gmail.com

This material is educational only, does not constitute legal advice, and covers onlyfederal, not state, law. Changes in applicable laws or regulations may require revision.Dentists should contact their personal attorneys for legal advice pertaining to HIPAAcompliance, the HITECH Act, and the U.S. Department of Health and Human Servicesrules and regulations.