Palm Dental Professionals, PLLC

How We May Use and Disclose Health Information About You

We may use and disclose your health information for purposes of treatment, payment, and healthcare operations.

Some information, such as HIV-related information, genetic information, substance use disorder treatment records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will comply with those protections where applicable.

Treatment

We may use and disclose your health information for your treatment. For example, we may disclose your information to specialists, laboratories, pharmacies, or other healthcare providers involved in your care.

Payment

We may use and disclose your health information to obtain payment for the treatment and services you receive from us or another provider involved in your care.

Payment activities include billing, collections, claims management, eligibility verification, and obtaining payment from you, your insurance company, or another responsible party.

Healthcare Operations

We may use and disclose your health information in connection with our healthcare operations.

Examples include:

• quality assessment and improvement
• staff training and education
• licensing and credentialing
• business management and administrative activities
• compliance and risk management

Individuals Involved in Your Care

We may disclose your health information to family members, friends, or other individuals identified by you when they are involved in your care or payment for your care.

If someone has legal authority to make healthcare decisions for you, we will treat that person as your personal representative.

Required by Law

We may use or disclose your health information when required by federal, state, or local law.

Public Health Activities

We may disclose your health information for public health activities such as:

• preventing or controlling disease
• reporting abuse or neglect
• reporting adverse reactions to medications
• product recalls
• exposure notifications
• reporting domestic violence when required

Health Oversight Activities

We may disclose your information to licensing boards, government agencies, auditors, and other oversight agencies as authorized by law.

Judicial and Administrative Proceedings

We may disclose health information in response to court orders, subpoenas, lawful discovery requests, or other legal processes.

Law Enforcement

We may disclose PHI for law enforcement purposes as permitted by HIPAA and applicable law.

Research

We may disclose health information for approved research purposes when appropriate privacy protections are in place.

Workers’ Compensation

We may disclose PHI as necessary to comply with workers’ compensation laws and similar programs.

Coroners, Medical Examiners, and Funeral Directors

We may disclose PHI when necessary for identification, cause of death determinations, or funeral arrangements.

National Security and Correctional Institutions

We may disclose health information when required for military, national security, correctional institution, or lawful custody purposes.

Secretary of Health and Human Services

We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required for HIPAA compliance investigations.

Other Uses and Disclosures

Your written authorization is required for:

• most marketing uses of PHI
• sale of PHI
• disclosure of psychotherapy notes
• uses or disclosures not otherwise described in this Notice unless otherwise permitted by law

You may revoke an authorization in writing at any time, except to the extent we have already acted in reliance on that authorization.

Your Health Information Rights

You have the right to:

Access

Inspect and obtain copies of your health records, with limited exceptions.

Requests must be made in writing. Reasonable cost-based fees may apply where permitted by law.

Request Restrictions

Request restrictions on certain uses and disclosures of your PHI.

We are not required to agree to all requests except where required by law.

Alternative Communications

Request confidential communications by alternative means or at alternative locations.

Amendment

Request correction or amendment of your health information if you believe information is incorrect or incomplete.

Accounting of Disclosures

Request an accounting of certain disclosures of your PHI made by our office.

Breach Notification

Receive notification if a breach of your unsecured protected health information occurs.

Paper Copy of This Notice

Receive a paper copy of this Notice even if you have agreed to receive it electronically.

Questions and Complaints

If you have questions about this Notice or believe your privacy rights have been violated, please contact our Privacy Official.

You may also file a complaint with the U.S. Department of Health and Human Services.

We will not retaliate against you for filing a complaint.

Privacy Official Contact Information

Privacy Official: Kara Morine

Palm Dental Professionals, PLLC
224 Chimney Corner Lane, Suite #3022
Jupiter, FL 33458

Phone: 561-404-4325
Fax: 561-448-1778
Email: info@palmdentalpros.com
Website: www.palmdentalprofessionals.com

Acknowledgment of Receipt of Notice of Privacy Practices and Communication Consent

Notice of Privacy Practices Acknowledgment

I acknowledge that I have been offered a copy of the Notice of Privacy Practices of Palm Dental Professionals, PLLC.

I understand that the Notice of Privacy Practices describes how my protected health information may be used and disclosed for purposes of treatment, payment, healthcare operations, and as otherwise permitted or required by law.

I understand that Palm Dental Professionals, PLLC is committed to protecting the privacy and security of my health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

I understand that I have the right to:

• inspect and obtain a copy of my health records
• request restrictions on certain uses and disclosures
• request confidential communications
• request amendments to my health information
• receive an accounting of certain disclosures
• receive notification of certain breaches
• file a complaint if I believe my privacy rights have been violated

I understand that Palm Dental Professionals, PLLC reserves the right to change its Notice of Privacy Practices and that a revised notice will be made available upon request and on the practice website.

Communication Consent

By signing below, I consent to receive communications from Palm Dental Professionals, PLLC regarding:

• appointment reminders
• scheduling and treatment coordination
• treatment follow-up
• billing notifications
• insurance and payment matters
• general office communication
• phone calls and voicemail messages
• email communication
• SMS text messaging for healthcare operations and patient communication

I understand that message frequency may vary and that message and data rates may apply.

I understand that I may opt out of SMS communications at any time by replying STOP.

Reply HELP for support.

For more information, please review our Privacy Policy available at:

www.palmdentalprofessionals.com

I understand that consumer information and mobile opt-in information will not be shared with third parties for marketing purposes.

Patient Information

Patient Name:

Date of Birth:

Signature:

Date:

If signed by personal representative:

Representative Name:

Relationship to Patient: