stock photo of a boy This notice describes the privacy policies of our dental office. First and foremost, we strive to maintain confidentiality of your dental treatment information. There are times, however, when identifiable health information must be disclosed to specific entities such as your insurance carrier. Herein we describe how this confidential dental and health information is used and disclosed, and how you can gain access to your confidential information.


Dental offices are required by applicable federal and state law to maintain the privacy of your dental health information generated for patients during the course of treatment. Through recent legislation dental offices are now required to notify all patients about our privacy practices, our legal duties concerning these practices, and your rights concerning your health information. These office privacy policies took effect April 14, 2003, and will remain in effect until amended by our office.

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices effective for all health information that we collect and maintain, including prior health information. As changes in our privacy practices are made, we will notify our patients of these changes and make amended office Privacy Policy statements available upon request.

Our patients are welcome to request a copy of our privacy policies at any time. Please keep this information on file with other documents from our office and check with us for any amended versions or changes.


We use and disclose health information about you and/or family members for purposes of treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to your physician or other healthcare providers rendering treatment to you.

Payment: We may use and disclose your health information by regular mail, fax, or electronic transmission to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in conjunction with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of personnel who work in our office, conducting training programs, evaluating performance, accreditation, certification, licensing or credentialing activities. Your health information may also be disclosed to our attorneys and consultants as necessary to respond to any type of investigation or legal action pertaining to the quality of treatment provided to you.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.

Disclosure to Family and Friends: You have the right for us to disclose your own personal health information to you as described in the Patient Rights section of our Privacy Policies. We may also disclose your health information to a family member, friend, or other person to the extent necessary to help with your dental care or with payment for your dental care, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to identify or assist in the identification of you or a family member in conjunction with a forensic investigation. In the event of your incapacity or in emergency circumstances, we will disclose health information based on our professional judgment. In that instance we will disclose only that information that is directly relevant to the treating entity's involvement in your health care. We will also use our professional judgment and experience to make reasonable inferences of your best interest in allowing a person to pick up prescriptions, dental supplies, x-rays or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your specific written authorization.

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

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody the protected health information of inmates or patients under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

Minimal Necessary Disclosures: We will not make disclosures of your health information to a greater degree than we consider minimally necessary for the purposes of each disclosure.


Access: You have the right to look at or obtain copies of your health information, with limited exceptions. Illinois law (R-156-69-502-7) specifies that original records must remain in the possession of the treating dentist for seven years. 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. Your request needs to be in writing. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. If you request copies, we will charge you $0.10 for each page, an administrative fee of $20.00 for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee related to the complexity of the summary. Contact us for a full explanation of our duplication fee structure.

Disclosure Accounting: You have the right to receive a list of instances in which we disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 15, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We reserve the right to discuss your request and we are not required to agree to these additional restrictions. If we agree to abide by your request, we may be exempted from this agreement in the event of 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. Your request must be in writing and specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We reserve the right to deny your request under certain circumstances.


If you want additional 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 complain to us using the contact information listed at the end of this Notice. 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 with the U.S. Department of Health and Human Services 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.