HIPAA Notice of Privacy Practices

Smiles on Main Family Dentistry (“we,” “our,” “us”) is required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to maintain the privacy of your protected health information (PHI), provide you with this Notice of our legal duties and privacy practices regarding PHI, abide by the terms of the Notice currently in effect, and notify you following a breach of unsecured PHI.

1. How We May Use and Disclose Your PHI

For Treatment

We use and disclose your PHI to provide, coordinate, or manage your dental care and any related services. For example, a hygienist may review a dentist's notes before a cleaning, or we may share x-rays with a specialist we refer you to.

For Payment

We use and disclose your PHI to obtain payment for the services we provide. For example, we may share information with your insurance carrier to determine coverage, obtain pre-authorization, or bill for treatment you've received.

For Health Care Operations

We use and disclose your PHI for our internal operations — quality assessment, staff training, licensure activities, and business management. For example, we may review treatment records for quality improvement, or combine your PHI with others' to evaluate the effectiveness of the care we provide.

Appointment Reminders and Treatment Alternatives

We may contact you by phone, text message, email, or mail to remind you of appointments, follow up on treatment, or share information about treatment alternatives or other health-related benefits and services we offer.

Family and Friends Involved in Your Care

With your agreement, we may disclose relevant PHI to a family member, friend, or other person you have identified as involved in your care or payment for your care. If you are incapacitated or in an emergency, we may use professional judgment to disclose information if we believe it is in your best interest.

Required or Permitted by Law

We may use and disclose your PHI without your authorization when:

• Required by federal, state, or local law.
• Needed for public health activities (e.g., reporting disease, birth, or death; FDA-regulated product tracking).
• Reporting suspected abuse, neglect, or domestic violence to appropriate authorities.
• For health oversight activities (audits, investigations, licensure).
• Requested by a court order, subpoena, or other lawful process.
• Disclosed to law enforcement as required or permitted by law.
• Relating to decedents (to coroners, medical examiners, funeral directors).
• For organ or tissue donation, research (under an IRB-approved protocol), or to avert a serious threat to health or safety.
• Disclosed for specialized government functions (military, national security, correctional institutions).
• For workers' compensation claims as authorized by law.

2. Uses and Disclosures That Require Your Written Authorization

Other uses and disclosures of your PHI not described in this Notice will be made only with your written authorization. You may revoke any authorization at any time, in writing, except to the extent we have already relied on it. Uses and disclosures that always require your written authorization include:

• Marketing — most communications for marketing purposes.
• Sale of PHI — any disclosure that constitutes a sale of your PHI.
• Psychotherapy notes — if we ever maintain any (uncommon in a dental setting).

3. Your Rights Regarding Your PHI

Right to Inspect and Copy

You have the right to inspect and obtain a copy of the PHI we maintain about you — typically your dental records and billing information. Submit a written request to our office; we will respond within 30 days. We may charge a reasonable, cost-based fee for copies.

Right to Request an Amendment

If you believe PHI we have about you is incorrect or incomplete, you may request an amendment in writing, with a reason supporting your request. We may deny the request in certain circumstances (for example, if the information was not created by us) and will respond in writing.

Right to an Accounting of Disclosures

You have the right to receive a list of certain disclosures we have made of your PHI, other than disclosures for treatment, payment, health care operations, or those you authorized. Submit a written request specifying a time period (not more than six years, and not before April 14, 2003). The first accounting in any 12-month period is free; additional requests may be subject to a reasonable, cost-based fee.

Right to Request Restrictions

You have the right to request restrictions on how we use or disclose your PHI for treatment, payment, or health care operations. We are not required to agree to requested restrictions, except that we will restrict disclosure to a health plan of PHI pertaining solely to a service or item for which you have paid out of pocket in full.

Right to Confidential Communications

You have the right to request that we communicate with you about health matters in a certain way or at a certain location — for example, by calling a specific phone number or mailing to an address you designate. We will accommodate reasonable requests.

Right to a Paper Copy of This Notice

You have the right to a paper copy of this Notice, even if you have agreed to receive it electronically. Request a copy at any time at the front desk or by contacting our office.

Right to Be Notified of a Breach

You have the right to be notified if there is a breach of your unsecured PHI as required by HIPAA.

4. Our Duties

We are required by law to:

• Maintain the privacy of your PHI.
• Provide you with this Notice describing our legal duties and privacy practices.
• Abide by the terms of the Notice currently in effect.
• Notify you of a breach of unsecured PHI.

5. Changes to This Notice

We reserve the right to change this Notice at any time. A revised Notice will be effective for all PHI we then maintain as well as PHI we receive in the future. The current Notice will be posted in our office and on our website with a new effective date. You may request a copy of the current Notice at any time.

6. Complaints

If you believe your privacy rights have been violated, you may file a written complaint with our office or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with us, contact our Privacy Officer using the information below. You will not be retaliated against for filing a complaint.

To file a complaint with HHS, visit hhs.gov/hipaa/filing-a-complaint or call 1-877-696-6775.

7. Contact Us

To exercise any of your rights, file a complaint, or ask questions about this Notice or our privacy practices, contact our Privacy Officer:

Privacy Officer
Smiles on Main Family Dentistry
4825 Main St Ste 10
Spring Hill, TN 37174
Phone: (615) 614-2201
Email: info@smilesonmaintn.com

This Notice is separate from our Website Privacy Policy, which covers information collected through smilesonmaintn.com. HIPAA applies only to protected health information we maintain as a dental provider.