Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to
give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must
follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 13, 2003, and will
remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted
by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice
effective for all health information that we maintain, including health information we created or received before we made the
Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies
of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
We may use or disclose your health information to a physician or other healthcare provider providing treatment
We may use and disclose your health information to obtain payment for services we provide to you.
We may use and disclose your health information in connection with our healthcare operations.
Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications
of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation,
certification, licensing or credentialing activities.
In addition to our use of your health information for treatment, payment or healthcare operations, you
may give us written authorization to use your health information to disclose it to anyone for any purpose. If you give us an
authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by
your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health
information for any reason except those described in this Notice.
To Your Family and Friends:
We must disclose your health information to you, as described in the Patient Rights section of
this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to
help with your healthcare with payment for your healthcare, but only if you agree that we may do so.
Persons Involved in Care:
We may use or disclose health information to notify, or assist in the notification of (including identifying
or locating) a family member, your personal representative or another person responsible for your care, of your location,
your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide
you with an opportunity to object to such use or disclosures. In the event of your incapacity or emergency circumstances, we
will disclose health information based on a determination using our professional judgment disclosing only health information
that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our
experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled
prescriptions, medical supplies, x-rays, or other similar forms of health information.
Marketing Health-Related Services:
We will not use your health information for marketing communications without your
Required by Law:
We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect:
We may disclose your health information to appropriate authorities if we reasonably believe that you are a
possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health
information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
We may disclose to military authorities the health information of Armed Forces personnel under certain
circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence,
and other national security activities. We may disclose to correctional institution or law enforcement official having
lawful custody of protected health information of inmate or patient under certain circumstances.
We may use or disclose your health information to provide you with appointment reminders (such
as voice mail messages, postcards, or letters).
You have the right to look at or get copies of your health information, with limited exceptions. You may request that
we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do
so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access
by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses
such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If
you request copies, we will charge you $0.60 for each page, $10 per hour for staff time to locate and copy your health information,
and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee
for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health
information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)
You have the right to receive a list of instances in which we or our business associates disclosed your
health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last
6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you
a reasonable, cost-based fee for responding to these additional requests.
You have the right to request that we place additional restrictions on our use or disclosure of your health information.
We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an
You have the right to request that we communicate with you about your health information by
alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative
means or location, and provide satisfactory explanation how payments will be handled under the alternative means or
location you request.
You have the right to request that we amend your health information. (Your request must be in writing, and it
must explain why the information should be amended.) We may deny your request under certain circumstances.
If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice
in written form.
USES AND DISCLOSURES OF HEALTH INFORMATION
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned
that we may have violated your privacy rights, or you disagree with a decision we made about access to your health
information or in response to a request you made to amend or restrict the use or disclosure of your health information or to
have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information
listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and
Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human
Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint
with us or with the U.S. Department of Health and Human Services.
Contact Officer: Marc Zaslow D.D.S.
Address: 10 FILA WAY, SUITE 201B