NOTICE OF PRIVACY PRACTICES

Effective Date: 1-1-2026

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Privacy Office Contact Information

Privacy Officer: Nate Heffelfinger
Phone: (260) 925-4290
Address: 1210 E. 7th St, Auburn, IN, 46706

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

The most common reason why we use or disclose your health information is for treatment, payment, or health care operations.

Treatment: Examples include setting up an appointment; examining your teeth; prescribing medications and faxing them to be filled; referring you to another doctor or clinic; or obtaining copies of your health information from a previous professional.
Payment: Examples include asking about your health or dental care plans; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency/attorney).
Health Care Operations: These are administrative and managerial functions necessary to run our office. Examples include financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of records.

We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we usually will not ask you for special written permission.

SPECIAL PROTECTIONS FOR SUBSTANCE USE DISORDER (SUD) RECORDS

For patients receiving treatment for substance use disorders, federal law (42 CFR Part 2) provides additional privacy protections:

Heightened Confidentiality: We will not disclose records identifying you as having an SUD in civil, criminal, administrative, or legislative proceedings without your specific written consent or a specialized court order.
Single Consent for TPO: You may choose to provide a single, written “Global Consent” for all future treatment, payment, and health care operations.
Right to Revoke: You have the right to revoke this consent at any time in writing, except to the extent that we have already taken action.
Accounting of Disclosures: You may request a list of certain SUD record disclosures made for treatment, payment, and health care operations for the three years prior to your request.
Prohibition on Redisclosure: Recipients of your SUD records are generally prohibited from sharing that information further without express written consent or legal permission.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

In limited situations, the law allows or requires us to disclose information without your permission, including:

Mandated reporting for public health purposes (contagious diseases, FDA notices).
Reporting suspected abuse, neglect, or domestic violence to authorities.
Health oversight activities (licensing, Medicare/Medicaid audits).
Judicial and administrative proceedings (subpoenas or court orders).
Law enforcement purposes (reporting crimes or identifying victims).
Medical examiners, funeral directors, or organ procurement organizations.
Health-related research and preventing serious threats to health or safety.
Specialized government functions (military, national security, protection of officials).
De-identified information and “limited data sets.”
Incidental disclosures and disclosures to “business associates” who assist our operations.

Note: Unless you object, we will also share relevant information about your care with family or friends helping with your dental care.

NOTIFICATION OF DATA BREACHES

We are required by law to maintain the privacy and security of your protected health information. In the event of a breach—the unauthorized acquisition, access, use, or disclosure of your unsecured health information—we will notify you promptly in writing via first-class mail (or email if previously agreed).

APPOINTMENT REMINDERS

We may contact you to remind you of appointments or available treatments. Unless you tell us otherwise, we will mail reminders on postcards and/or leave messages on your answering machine or with someone who answers your phone.

TELEHEALTH AND ELECTRONIC COMMUNICATIONS

We may offer virtual visits or communicate via patient portals, secure video, email, or text. Technology vendors helping deliver these services are required to protect your information.

Your Right: You may request confidential communications (specific phone numbers or addresses).
Risk: Electronic communications carry risks of interception. If you choose unencrypted email or text, you acknowledge these risks.

OTHER USES AND DISCLOSURES

We will not make any other uses or disclosures without a signed “authorization form.”

Most uses/disclosures for marketing or the sale of health information require written authorization.
You may revoke an authorization at any time in writing, though it will not apply to actions already taken.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

The law gives you the right to:

Request Restrictions: Ask us to limit certain uses/disclosures. We are not required to agree, except for services paid for out-of-pocket in full, where we must honor your request to keep the info from your health plan.
Confidential Communications: Ask to be contacted at a specific location or via a specific method.
Access and Copies: Review or get photocopies of your records (usually within 30 days). A fee for copies may apply.
Amend Records: Ask us to correct incorrect or incomplete information.
Accounting of Disclosures: Get a list of disclosures made over the last six years (excluding treatment, payment, operations, and authorized disclosures).
Paper Copy: Receive a paper copy of this notice at any time.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.

ACKNOWLEDGEMENT OF RECEIPT

You May Refuse to Sign This Acknowledgement

I, ______________________________________________________, have received a copy of this office’s Notice of Privacy Practices.

Print Name: ______________________________________________________

Signature: ______________________________________________________

Date: ______________________________________________________

For Office Use Only

We attempted to obtain written acknowledgement of receipt, but it could not be obtained because:

[ ] Individual refused to sign
[ ] Communications barriers prohibited obtaining the acknowledgement
[ ] An emergency situation prevented us from obtaining acknowledgement
[ ] Other: ______________________________________________________

Office Employee Signature: ______________________________________________________

Privacy Policy