Effective date: 2026-05-07
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.
Our commitment
Madison Square Dental is committed to protecting the privacy of your protected health information (PHI). This notice describes how we may use and disclose your PHI and your rights regarding that information.
How we may use and disclose your PHI
- Treatment: we use your PHI to provide dental treatment and coordinate with other healthcare providers.
- Payment: we use your PHI to bill insurance carriers and collect payment.
- Healthcare operations: we use PHI for quality assessment, staff training, and administrative tasks.
- Required by law: we may disclose PHI when required by federal, state, or local law.
Your rights
- Right to access your medical records
- Right to request amendments to your PHI
- Right to an accounting of disclosures we have made
- Right to request restrictions on uses or disclosures
- Right to confidential communications at an alternate location
- Right to a paper copy of this notice
Complaints
If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.
Contact
For questions about this notice or to exercise your rights, contact our Privacy Officer at:
Madison Square Dental
803 Washington Dr, Arlington, TX 76011
(817) 275-2229
This is a baseline HIPAA Notice of Privacy Practices. Please replace with your practice’s existing notice or have an attorney review before going live to ensure compliance with current HIPAA Privacy Rule requirements.