Notice of Privacy Practices

Your Information. Your Rights. Our Responsibilities.
My Smile Avenue

This notice describes how medical information about you may be used and disclosed and how you can access this information. Please review it carefully. “Protected Health Information” (PHI) refers to information about you—including demographic details—that can identify you or may be used to identify you, and that relates to your past, present, or future physical or mental health or condition, the provision of health care to you, or the payment for such health care services.

Your Rights Regarding Your PHI

You have certain rights when it comes to your health information. This section explains those rights and our responsibilities.

Access to Your Records
You have the right to view or obtain an electronic or paper copy of your medical record and other health information we maintain about you. Upon request, we will provide a copy or summary, usually within 30 days. A reasonable, cost-based fee may apply.

Correction of Your Records
If you believe that your health information is incorrect or incomplete, you may request that we amend it. We may deny your request, but if we do, we will provide a written explanation within 60 days.

Confidential Communications
You may request that we communicate with you in a specific way, such as contacting you at a different phone number or address. We will accommodate all reasonable requests.

Limiting What We Use or Share
You may request that we restrict how your information is used or shared for treatment, payment, or healthcare operations. Although we are not required to agree to all requests, we will consider them carefully. If you have paid in full out of pocket for a service, you may request that we do not share that specific information with your health insurer, and we will honor that request unless the law requires otherwise.

Accounting of Disclosures
You may request a list of the individuals or entities with whom we have shared your health information during the previous six years, along with the reasons for those disclosures. One list per year is provided at no cost. Additional lists within a 12-month period may incur a reasonable, cost-based fee.

Copy of This Notice
You may request a paper copy of this Notice of Privacy Practices at any time, even if you previously agreed to receive it electronically.

Choosing Someone to Act for You
If you have designated someone as your medical power of attorney or if a legal guardian has been appointed for you, that person has the authority to exercise your rights regarding your health information. We will verify this authority before taking action.

Filing a Complaint
If you believe your rights have been violated, you may file a complaint with us by email. You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by writing to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or submitting a complaint online. We will not retaliate against you for filing a complaint.

Your Choices

In certain situations, you have the right to express your preferences regarding how we share your information. For example, you may request or decline to have your information shared with family members, close friends, or others involved in your care. If you are unable to communicate your preference—for example, if you are unconscious—we may share information if we believe it is in your best interest. We may also share information when required to prevent or reduce a serious and imminent threat to health or safety.

Our Uses and Disclosures

How We Typically Use or Share Your Information

Treatment
We may use your health information and share it with healthcare professionals who are involved in your care. For example, your dentist and another healthcare provider may need to coordinate your treatment.

Healthcare Operations
We may use and disclose your health information to manage our practice, improve services, and contact you when necessary. This includes quality assessment, training, and administrative activities.

Billing and Payment
We may use and share your health information to bill and receive payment from insurance companies or other entities. For example, your health plan may require information about your treatment so it can process claims.

Other Permitted Uses and Disclosures

We may also use or share your health information when permitted or required by law, typically for purposes that support public health, safety, or government functions. Before sharing information in these situations, we must meet specific legal requirements.

Public Health and Safety
We may share information for purposes such as reporting suspected abuse, neglect, or domestic violence, and preventing or reducing a serious threat to anyone’s health or safety.

Research
We may use or share your health information for health research when permitted by law.

Legal Compliance
We will share information when required by federal or state laws, including with the Department of Health and Human Services to demonstrate compliance with privacy laws.

Workers’ Compensation, Law Enforcement, and Government Functions
We may share information for workers’ compensation claims, law enforcement purposes, health oversight activities, and special government functions such as national security and presidential protective services.

Legal Proceedings
We may disclose your health information in response to a court or administrative order.

Our Responsibilities

We are legally required to maintain the privacy and security of your protected health information. If a breach occurs that may compromise your information, we will notify you promptly. We must follow the duties and privacy practices outlined in this notice and provide you with a copy upon request. We will not use or disclose your information in ways not described here unless you provide written authorization. You may revoke such authorization at any time by providing written notice.

Changes to This Notice

We may update the terms of this Notice of Privacy Practices and the revised version will apply to all health information we maintain. The updated notice will be available in our office and on our website, and you may request a copy at any time.