Patient Privacy Policy

Notice of Privacy Practices for Protected Health Information

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!

With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment,and health care operations. Protected health information (PHI) is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Examples of uses of your health information for treatment purposes:

Setting up an appointment for you; examining your teeth, mouth and oral health;referring you to another dentist for care; or getting copies of your health information from another professional that you may have seen before us.

Examples of use of your health information for payment purposes:

Asking you about your dental or medical care plans, or other sources of payment;preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency).

Examples of Use of Your Information for Health Care Operations:

Financial or billing audits, internal quality assurance; and defense of legal matters.

Your Health Information Rights

The health record we maintain and billing records are the physical property of the practice. The information in it,however, belongs to you. You have aright to:

Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request but we will comply with any request granted;

Request a restriction on disclosures of medical information to a health plan for purposes of carrying out payment or health care operations; and the PHI pertains solely to a health care service for which the provider has been paid out of pocket in full we must comply with this request;

Request that you be allowed to inspect and copy your health record and billing record you may exercise this right by delivering the request in writing to our office;

Appeal a denial of access to your protected health information except in certain circumstances;

Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office;

File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information;

Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;

Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office; and,

Elect to opt out of receiving further fundraising communications from the office/hospital

Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.

If you want to exercise any of the above rights, please contact our Business Manager at (607) 733-3760 or 451 W. Church St. Elmira, NY 14901 in person or in writing, during normal hours. S[he] will provide you with assistance on the steps to take to exercise your rights.

Our Responsibilities

The practice is required to:

Maintain the privacy of your health information as required by law;

Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you;

Abide by the terms of this Notice;

Notify you if we cannot accommodate a requested restriction or request;

Accommodate your reasonable requests regarding methods to communicate health information with you, and

Notify you if you are affected by a breach of unsecured PHI

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain.If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice” or by visiting our office and picking up a copy.

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact our Business Manager at (607)733-3760 or 451 W. Church St. Elmira, NY 14901.

Additionally,if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to our Business Manager at (607) 733-3760 or 451 W. Church St. Elmira, NY 14901. You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services whose street address26 Federal Plaza – Suite3312 New York, NY 10278 and e-mail address is [email protected].

We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services(HHS) as a condition of receiving treatment from the practice.

We cannot, and will not, retaliate against you for filing a complaint with the Secretary.

Other Disclosures and Uses


Unless you object, we may use or disclose your protected health information to notify,or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Communication with Family

Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency.

Food and Drug Administration (FDA)

We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Workers Compensation

If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health

As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease,injury, or disability.

Abuse & Neglect

We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Correctional Institutions

If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health and safety of other individuals.

Law Enforcement

We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.

Health Oversight

Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings

We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.

Other Uses

Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized bylaw or with your written authorization and you may revoke the authorization as previously provided.


Effective Date: September 2013