Notice of Privacy Act

 This notice describes how medical and dental information about you and/or your child may be used and disclosed and how you can get access to this information. Please review it carefully.

Your protected health information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects.

  1. To other health care providers (i.e., your or your child’s general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to your or your child (i.e., to determine the results of cleaning, surgery, etc.);
  2. 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.);
  3. 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;
  4. Internally, to all staff members who have any role in you or your child’s treatment; and or,
  5. To other patients and third parties who may see or over hear incidental disclosures about your or your child’s treatment, scheduling, etc.;
  6. To your family and close friends involved in your or your child’s treatment;
  7. 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;

And other uses or disclosures of your/ or your child’s protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

  1. Request restrictions on the use and disclosure of your/ or your child’s protected health information;
  2. Request confidential communication of your/ or your child’s protected health information;
  3. Inspect and obtain copies of your/ or your child’s protected health information through asking us;
  4. Amend or modify your/ or your child’s protected health information in certain circumstances;
  5. Receive an accounting of certain disclosures made by us of your/ or your child’s protected health information; and,
  6. 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.)

We have the following duties under the privacy rules:

  1. 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;
  2. To abide by the terms of our Privacy Notice that is currently in effect;
  3. To advise you of 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.

Please note that we are not obligated to:

  1. Honor any request by you to restrict the use of disclosure of your protected health information;
  2. Amend your protected health information if, for example, it is accurate and complete, or,
  3. 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.

This privacy notice is effective as of the date of your signature.  If you have any questions about the information on this Notice, please ask for our Privacy Person or direct your questions to his person at our office address. Thank you.


 I hereby acknowledge that I have received and reviewed a copy of this Privacy Notice

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Patient/Responsible Party                                                                    Date