Notice of Privacy Practices (HIPAA)

Notice of Privacy Practices (HIPAA)

Madison Square Dental

This Notice of Privacy Practices describes how medical and dental information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Madison Square Dental is required by law to maintain the privacy and security of your protected health information (PHI) and to provide you with this notice explaining our legal duties and privacy practices.

Our Responsibilities

Madison Square Dental is required by law to:

• Maintain the privacy and security of your protected health information
• Provide you with this Notice of Privacy Practices
• Follow the terms of this notice currently in effect
• Notify you promptly if a breach occurs that may have compromised the privacy or security of your information

We will not use or disclose your information other than as described in this notice unless you provide written authorization.

How We May Use and Disclose Your Health Information

We may use and share your health information for the following purposes:

Treatment

We may use your health information to provide, coordinate, or manage your dental care and related services.

Example:

• Sending X-rays to a specialist
• Discussing treatment plans with other healthcare providers involved in your care

Payment

We may use and disclose your information to bill and obtain payment from insurance companies or other third parties.

Example:

• Submitting dental claims to your insurance carrier
• Providing treatment information required by your insurer

Healthcare Operations

We may use and disclose your information for business operations necessary to run our practice.

Example:

• Quality assessment and improvement
• Staff training
• Licensing and accreditation activities
• Administrative and financial management

Other Permitted Uses and Disclosures

We may also disclose your information when permitted or required by law, including:

Public Health Activities

To report disease, injury, or public health concerns to government authorities.

Health Oversight

To agencies responsible for overseeing healthcare systems, audits, or investigations.

Legal Requirements

When required by court orders, subpoenas, or other legal processes.

Law Enforcement

When requested by law enforcement in certain circumstances.

Workers’ Compensation

For claims related to work-related injuries or illness.

Serious Threat to Health or Safety

When necessary to prevent a serious threat to your health or safety or the safety of others.

Uses That Require Your Authorization

We will obtain your written permission before using or sharing your information for purposes such as:

• Marketing communications unrelated to your care
• Sale of protected health information
• Certain disclosures not otherwise permitted by HIPAA

You may revoke your authorization at any time in writing.

Your Rights Regarding Your Health Information

You have the following rights regarding your protected health information.

Right to Access

You may request a copy of your dental and medical records.

Requests must be submitted in writing. Reasonable fees may apply for copies.

Right to Request Amendments

If you believe your health information is incorrect or incomplete, you may request that we correct or update the information.

Right to Request Restrictions

You may request restrictions on certain uses or disclosures of your health information.

We are not required to agree to all requested restrictions but will consider them carefully.

Right to Request Confidential Communications

You may request that we communicate with you in a specific way or at a specific location.

Example:

• Calling a different phone number
• Sending mail to a different address

Right to an Accounting of Disclosures

You may request a list of certain disclosures of your health information made by our practice.

Right to a Paper Copy of This Notice

You may request a paper copy of this Notice of Privacy Practices at any time, even if you have received an electronic copy.

Changes to This Notice

Madison Square Dental reserves the right to change the terms of this notice. Any updates will apply to all health information we maintain.

The updated notice will be posted in our office and on our website.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with Madison Square Dental or with the U.S. Department of Health and Human Services.

You will not be penalized or retaliated against for filing a complaint.

To file a complaint with our office, please contact us using the information below.

Contact Information

Madison Square Dental
Arlington, Texas
Phone: (817) 275-2229
Website: https://www.madisonsquaredentaltx.com

You may also file a complaint with:

U.S. Department of Health and Human Services
Office for Civil Rights (OCR)
https://www.hhs.gov/ocr

Acknowledgement of Receipt

Patients may be asked to sign an acknowledgement stating they received this Notice of Privacy Practices. Signing the acknowledgement does not mean you agree with the notice, only that you received it.