We are required by applicable federal and state law to maintain the privacy of your health information.  We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information.  We must follow the privacy practices that are described in this Notice while it is in effect.  This Notice takes effect April 14, 2003, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law.  We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes.  Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time.  For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

We use and disclose health information about you for treatment, payment, and healthcare operations.  For example:

Treatment: A nurse obtains treatment information about you and records it in a health record.  During the course of your treatment, the doctor determines a need to consult with another specialist in the area.  The doctor will share this information with such specialist and obtain input.

Payment: We submit a request for payment to your health/dental insurance company.  The health/dental insurance company requests information from us regarding medical/dental care given. We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations:  We may use and disclose your health information in connection with our healthcare operations.  Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization:  In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose.  If you give us an authorization, you may revoke it in writing at any time.  Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.  Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

Persons Involved In Care:  We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death.  If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures.  In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the personís involvement in your healthcare.  We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Appointment Reminders:  We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).


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

Access: You have the right to look at or get copies of your health information, with limited exceptions.  You may request that we provide copies in a format other than photocopies.  We will use the format you request unless we cannot practicably do so.  (You must make a request in writing to obtain access to your health information.  You may obtain a form to request access by using the contact information listed at the end of this Notice.  We will charge you a reasonable cost-based fee for expenses such as copies and staff time.  You may also request access by sending us a letter to the address at the end of this Notice.  If you request copies, we will charge you $1.00 per page for pages 1-10; 50 cents for pages 11-50; and 25 cents for pages 51 and higher plus actual cost of postage if you want the copies mailed to you.  If you request an alternative format, we will charge a cost-based fee for providing your health information in that format.  If you prefer, we will prepare a summary or an explanation of your health information for a fee.  Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting:  You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003.  If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. 

Other Uses and Disclosures:

  • Our dental office may disclose a patientís PHI to that patient on request.

  • Our dental office may disclose to a patientís personal representative PHI relevant to the representative capacity.  We will not disclose to a personal representative we reasonably believe may be abusive to a patient any PHI we reasonably believe may promote or further such abuse.

  • Our dental office will not use or disclose a patientís PHI for fundraising purposes without the patientís Authorization.

  • Our dental office will not use or disclose PHI for marketing without a patientís Authorization unless the marketing is in the form of a promotional gift of nominal value that we provide, or face-to-face communications between us and the patient.

  • 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.

  • 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 personís involvement in your care or in payment for such care if you do not object or in an emergency.

  • Our dental office may use or disclose PHI in the following types of situations, provided procedures specified in the Privacy Rules are followed: 

  1. For public health activities;

  2. To health oversight agencies;

  3. To coroners, medical examiners, and funeral directors;

  4. To employers regarding work-related illness or injury;

  5. To the military;

  6. To federal officials for lawful intelligence, counterintelligence, and national security activities;

  7. To correctional institutions regarding inmates;

  8. In response to subpoenas and other lawful judicial processes;

  9. To law enforcement officials;

  10. To report abuse, neglect, or domestic violence;

  11. As required by law;

  12. As part of research projects; and

  13. As authorized by state workerís compensation laws.


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

Restriction:  You have the right to request that we place additional restrictions on our use or disclosure of your health information.  We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication:  You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.)  Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. 

Amendment:  You have the right to request that we amend your health information.  (Your request must be in writing, and it must explain why the information should be amended.)  We may deny your request under certain circumstances. 

Electronic Notice:  If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.


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. 

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.


If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice.  You also may submit a written complaint to the U.S. Department of Health and Human Services.  We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information.  We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.


Contact Officer: Coralee Seifert, Office Manager

Telephone:  513-829-4111
Fax: 513-829-5140


Address: 1251 Nilles Road Suite 12 Fairfield OH  45014-7205


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