This notice describes how health information about you may be used and disclosed and how you can get access to this information.
This section explains your rights and some of your responsibilities to help you. Please review it carefully. If you have any questions
about this Notice please contact our Privacy Officer.
Get an electronic or paper copy of your dental record
You can ask to see or get an electronic or paper copy of your dental
record and other health information we have about you. Ask us how to do
We will provide a copy or a summary of your health information, usually
within 15 days of your request. We may charge a reasonable, cost-based
Ask us to correct your dental record
You can ask us to correct your health information if you think is
incorrect or incomplete. Ask us how to do this.
We may say "no" to your request, but we'll tell you why in writing
within 60 days.
Request confidential communications
You can ask us to contact you in a specific way (for example, home or
office phone) or to send mail to a different address.
- We will say "yes" to all reasonable requests.
Ask us to limit what we use or share
You can ask us not to use or share certain health information for
treatment, payment, or our operations.
We are not required to agree to your request, and we may say "no" if
it would affect your care.
If you pay for a service of health care item our-of-pocket in full, you
can ask us not to share that information for the purpose of payment or
our operations with your health insurer.
We will say "yes" unless a law requires us to share that
Get a list of those with whom we've shared information
You can ask for a list (accounting) of the times we've shared your
health information for six years prior to the date you ask, who we
shared it with and why.
We will include all the disclosures except for those about treatment,
payment, and health care operations, and certain other disclosures (such
as any you asked us to make). We'll provide one accounting a year for
free but will charge a reasonable, cost-based fee if you ask for another
one within 12 months.
Get a copy of this Privacy Notice
You can ask for a paper copy of this notice at any time, even if you
have agreed to receive the notice electronically. We will provide you
with a paper copy promptly.
Choose someone to act for you
If you have given someone medical power of attorney or if someone is
your legal guardian, that person can exercise your rights and make
choices about your health information
- We will make sure the person has this authority and an act for you before we take any action.
File a complaint if you fell your rights are violated
You can file a complaint with the U.S Department of Health and Human
Services Officer for Civil Rights by sending a letter to 200
independence Avenue, S.W., Washington, D.C. 20201, calling
1-877-696-6775, or visiting
www.hhs.gov/ocr/privacv/hiPpa / complaints/
- We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we
share. If you have a clear preference for how we share your information in
the situations describe below, talk to us. Tell us what you want us to do,
and we will for your instructions.
You have both the right and choice to tell us to:
Share information with your family, close friends, or other involved in
- Share information in a disaster relief situation
- Contact you for fundraising efforts
If you are not able to tell us your preference, for example if you are
unconscious, we may go ahead and share your information if we believe it
is in your best interest. We may also share your information when needed
to lessen serious and imminent threat to health or safety.
We never share your information unless you give us written permission for:
Marketing purposes, but you have the right to have your name removed
from our mailing list within 45 days of your request.
Sale of your information, wherein the direct or indirect remuneration
received for the sale of the information may not exceed our reasonable
costs of preparing or transmitting the protected health information.
In the case of fundraising:
We may contact you for fundraising efforts, but you can tell us not to
contact you again
OUR USES AND DISCLOSURES
How do we typically use of share your health information? We typically use
or share your health information in the following ways.
Your protected health information may be used and disclosed by our
office and others outside of our office that is involved in your dental
care. We will use and disclose your protected health information to
other dentist and physicians to provide, coordinate or manage your
health care. For example, your protected health information may be
provided to another dental specialist to whom you have been referred to
ensure that the necessary information is available to diagnose or treat
We may use or disclose your protected health information in order to
support the business activities if our practice. Healthcare operations
include quality assessment activities, employee review activities,
licensing or credentialing activities, conducting training and
conducting auditing or review activities. For example, we may use a
sign- in sheet at the reception desk where you will be asked to sign
your name and indicate your doctor. We may also call your name in the
waiting room when your doctor is ready to see you. We may send you
reminder postcards or telephone you to remind you of your appointment,
we may also send you a newsletter about our practice and the services we
offer. You may contact our Privacy Officer to request that these
materials not be sent to you.
Your protected health information may be used and disclosed to pay your
health care bills. Your protected health information will be used to
obtain payment for services we provided to you. This may include certain
activities that your insurance plan may undertake before it approves or
pay for the services we recommended.
We will share your protected health information with third party
Business Associates that performs various activities for our practice.
Whenever we disclose your protected health information to a business
associate. We will have written contract that will protect the privacy
of your protected health information.
Help with public health and safety issues
We can share health information about you for certain situations such
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone's health or safety
Comply with the law
- We can use or share health information about you:
- For workers' compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
For special government functions such as military, national security,
and presidential protective services
Respond to lawsuits & legal actions
We can share health information about you in response to a court or
administrative order, or in response to a subpoena.
We are required by law to maintain the privacy and security of your
protected health information.
We will let you know promptly if a breach occurs that may have
compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice
and give you a copy of it.
We will not use or share your information other that as descried in this
notice unless you tell us we can in writing. If you tell us we can, you
may change your mind at any time. Let us know in writing if you change
For more information see:
CHANGES TO THE TERMS OF THIS NOTICE
We can change the terms of this notice, and the changes will apply to all
information we have about you. The new notice will be available upon
request, in our office, and on our website.
Date: March 7, 2015
Privacy Officer: Ernesto Trevino (Maria Herrera (Harlingen Office ) and Alma Pineda (Edinburg Office) )
Telephone: (956) 412-9500 (Harlingen Office) ; (956) 994.9500 (Edinburg Office)
Address: 1610 E. Harrison Ave. Suite A, Harlingen, Tx 78550 ; 5421 South McColl Rd., Edinburg, Tx 78539