Notice of Privacy Practices

Montville Center for Dentistry, LLC is required by law to protect the privacy of your protected health information, to give you this notice of our legal duties and privacy practices, and to follow the terms of the notice currently in effect.

Protected health information means information that identifies you and relates to your dental or medical care, or to payment for that care.

We use and disclose your health information to provide, coordinate, and manage your dental care. For example, we may share records with a specialist we refer you to, with a dental laboratory making a restoration for you, or with your physician when your medical condition affects your treatment.

We use and disclose your health information to bill and collect payment for the care we provide. For example, we may send claim information to your dental or medical plan, confirm coverage and benefits, obtain prior authorization, or provide records to a billing service or collection agency working on our behalf.

We use and disclose your health information to run the practice and keep the quality of care high. Examples include appointment reminders, quality review, staff training and evaluation, licensing and accreditation, and business planning or administration.

We may use or disclose your health information without your authorization when:

• Required by federal, state, or local law
• Needed for public health activities, such as reporting disease or product safety issues
• Reporting suspected abuse, neglect, or domestic violence as the law allows or requires
• Responding to health oversight agencies conducting audits, inspections, or investigations
• Responding to a court order, subpoena, or other lawful legal process
• Requested by law enforcement in the limited circumstances the law permits
• Necessary to avert a serious and imminent threat to health or safety
• Related to workers' compensation claims
• Involving coroners, medical examiners, funeral directors, or organ donation
• Used for research approved under an established review process
• Involving military, national security, or correctional institution requirements

We may also share information with a family member, friend, or other person you involve in your care or payment for your care, when you agree or when we can reasonably infer from the circumstances that you do not object.

Any other use or disclosure requires your written authorization. That includes most uses of psychotherapy notes, marketing, and any sale of your health information. You may revoke an authorization in writing at any time, except where we have already acted on it.

• Inspect and copy your records, including an electronic copy where we keep them electronically
• Ask us to correct information you believe is wrong or incomplete
• Request confidential communication at a different address or by a different method
• Request a restriction on certain uses and disclosures, which we are not always required to accept
• Require us to restrict disclosure to a health plan for care you paid for in full out of pocket
• Receive a list of certain disclosures we have made in the six years before your request
• Receive a paper copy of this notice even if you agreed to receive it electronically
• Be notified if a breach affects your unsecured health information
• Choose someone with legal authority to act for you and exercise these rights

To use any of these rights, contact our privacy contact listed below. We will tell you how to submit your request in writing and how long the response will take.

• We are required by law to maintain the privacy and security of your health information
• We must give you this notice of our legal duties and privacy practices
• We must follow the terms of the notice currently in effect
• We must let you know promptly if a breach affects the privacy or security of your information
• We will not use or share your information other than as described here unless you tell us in writing that we may

We may change this notice and make the new terms apply to all information we maintain, including information created or received before the change. The current notice will be posted in our office and on this page, with its effective date. You may request a paper copy at any time.

If you believe your privacy rights have been violated, you may file a complaint with our privacy contact below, or with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue SW, Washington, DC 20201. We will not retaliate against you for filing a complaint.

PLACEHOLDER: effective date of this notice, to be set by the practice.