Notice of Privacy Practices
Notice of Privacy Practices (.PDF)
THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CAREFULLY
The Health Insurance Portability and Accountability Act of 1996 revised
2013 (HIPAA) is a federal program that requires that all medical
records and other individually identified health information used or
disclosed by us in any form, whether electronically, on paper, or
orally, are kept properly confidential. This Act gives you, the
patient, significant new rights to understand and control how your
health information is used.
HIPAA provides penalties for covered entities that misuse personal
As required by HIPAA, we have prepared this explanation of how we are
required to maintain the privacy of your health information and how we
may use and disclose your health information.
We may use and disclose your medical records only for each of the
following purposes: treatment, payment and health care operations.
Treatment means providing, coordinating, or managing health cares and
related services by one or more health care providers. An example of
this would include teeth cleaning services which are performed here in
an ‘open-bay’ setting. You may opt out of this
setting by alerting a staff member of our office.
Payment means such activities as obtaining reimbursement for services,
confirming coverage, billing or collection activities, and utilization
review. An example of this would be sending a bill for your visit to
your insurance company for payment.
Health care operations include the business aspects of running our
practice, such as conducting quality assessment and improvement
activities, auditing functions, cost-management analysis, and customer
service. An example would be an internal quality assessment review.
We may also create and distribute de-identified health information by
removing all references to individually identifiable information.
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.
Any other uses and disclosures will be made only with your written
authorization. You may revoke such authorization in writing and we are
required to honor and abide by that written request, except to the
extent that we have already taken actions relying on your authorization.
You have the following rights with respect to your protected health
information PHI, which you can exercise by presenting a written request
to the Privacy Officer:
The right to request restrictions on certain uses and disclosures of
protected health information, including those related to disclosures to
family members, other relatives, close personal friends, or any other
person identified by you. We are, however, not required to agree to a
requested restriction. If we do agree to a restriction, we must abide
by it unless you agree in writing to remove it.
The right to inspect and copy, either paper or electronically, your
protected health information.
The right to amend your protected health information.
The right to receive an accounting of disclosures of protected health
information. If you have paid in full for a service out of pocket, you
then have the right to request the office not to disclose treatment
information for this service to a health plan.
The right to obtain a paper or electronic copy of this notice from us
We are required by law to maintain the privacy of your protected health
information and to provide you with notice of our legal duties and
privacy practices with respect to protected health information. We are
also obligated to notify you in the event of a breach of unsecured PHI
as required by the HITECH Act.
This notice is effective as of July 1st, 2013 and we are required to
abide by the terms of the Notice of Privacy Practices currently in
effect. We reserve the right to change the terms of our Notice of
Privacy Practices and to make the new notice provisions effective for
all protected health information that we maintain. We will post and you
may request a written copy of a revised Notice of Privacy Practices
from this office.
You have recourse if you feel that your privacy protections have been
violated. You have the right to file written complaint with our office,
or with the Department of Health & Human Services, Office of
Civil Rights, about violations of the provisions of this notice or the
policies and procedures of our office. We will not retaliate against
you for filing a complaint.
Please contact us for more
Richard H Gentzler III, DDS
Pediatric Dentisty, PLLC
106 Babb Drives
Lebanon, TN 37087
Fax: (615) 443-3696
For more information about
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, SW
Washington, DC 20201
Toll Free: 1-877-6775