Notice of privacy practices

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.

This Notice is provided by Beeline Orthodontics ("we," "us," or "our"). It describes how we may use and disclose your protected health information — health information that identifies you and relates to your care or to payment for your care — and your rights regarding that information.

Our legal duties

We are required by law to maintain the privacy of your protected health information, to give you this Notice of our legal duties and privacy practices, and to notify you following a breach of your unsecured protected health information. We are required to follow the terms of the Notice currently in effect.

We reserve the right to change this Notice and to make the revised Notice apply to protected health information we already maintain as well as to information we receive later. If we make a material change, we will post the revised Notice in our office and on our website and will provide a copy on request.

How we may use and disclose your information without your authorization

Treatment. We use and disclose your information to provide and coordinate your orthodontic care — for example, sending your records to your general dentist.

Payment. We use and disclose your information to obtain payment for our services — for example, submitting a claim to your dental benefit plan.

Health care operations. We use and disclose your information to run and evaluate our practice — for example, reviewing treatment outcomes.

Others involved in your care. We may disclose information relevant to a person's involvement in your care, or in payment for your care, to a family member or other person you identify. If you are present, we will give you an opportunity to object. If you are not present, or are unable to agree or object, we may use our professional judgment to decide whether the disclosure is in your best interest. We may also disclose information to an entity assisting in disaster relief so that your family can be notified of your location and condition.

We may also use or disclose your information without your authorization:

• when federal, state, or local law requires it;
• to public health authorities for public health activities, including required disease reporting and, where permitted, notifying a person who may have been exposed to a communicable disease, and to report problems with regulated products to the manufacturer or to the government agency that regulates them;
• to report suspected abuse, neglect, or domestic violence, as required or permitted by law;
• to agencies that oversee the health care system, for audits, investigations, inspections, licensure, and similar activities;
• in judicial and administrative proceedings, in response to a court or administrative order or, in limited circumstances, to other lawful process;
• to law enforcement officials, in the limited circumstances the law allows;
• to coroners, medical examiners, and funeral directors, and for organ, eye, or tissue donation;
• for research, when a review board has approved a waiver of authorization or the research otherwise meets the conditions the law requires;
• to prevent or lessen a serious and imminent threat to the health or safety of a person or the public;
• for specialized government functions, including military, national security, protective, and correctional purposes; and
• as authorized by laws relating to workers' compensation and similar programs.

Substance use disorder records. No matter what else this Notice describes, substance use disorder treatment records we receive from a program subject to 42 C.F.R. Part 2, and testimony relaying the content of those records, will not be used or disclosed in any civil, criminal, administrative, or legislative proceeding against you unless you give written consent or a court order is entered after notice and an opportunity to be heard is provided to you or to the holder of the record. A court order authorizing use or disclosure must be accompanied by a subpoena or other legal requirement compelling disclosure before the record is used or disclosed.

Uses and disclosures that require your written authorization

We will obtain your written authorization before we:

• use or disclose psychotherapy notes, except as HIPAA otherwise permits;
• use or disclose your information for marketing, other than a face-to-face communication with you or a gift of nominal value;
• sell your information, in any way HIPAA defines as a sale; or
• use or disclose your information for any other purpose not described in this Notice.

You may revoke an authorization in writing at any time, except to the extent we have already acted in reliance on it.

Your rights

To exercise any of these rights, contact our Privacy Officer using the information below. We may ask you to put your request in writing.

Inspect and copy. You may inspect and receive a copy of the health and billing records we use to make decisions about your care, including an electronic copy if we maintain the records electronically. In limited circumstances we may deny part of your request; if we do, we will tell you in writing and explain how you may ask for a review.

Amend. If you believe information in your record is incorrect or incomplete, you may ask us in writing to amend it and tell us the reason. We may deny your request; if we do, we will explain why in writing, and you may file a statement of disagreement that we will keep with your record.

Accounting of disclosures. You may request a list of certain disclosures we have made of your information during the six years before your request.

Request restrictions. You may ask us to restrict how we use or disclose your information for treatment, payment, or health care operations, or what we disclose to a person involved in your care. We are not required to agree, except that we must agree not to disclose information to your health plan for payment or health care operations if you, or someone on your behalf other than the plan, has paid us in full for the item or service and the disclosure is not otherwise required by law.

Confidential communications. You may ask us to communicate with you by a particular means or at a particular location. We will accommodate reasonable requests.

Paper copy of this Notice. You may receive a paper copy of this Notice at any time, even if you have agreed to receive it electronically.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with us by contacting our Privacy Officer using the information below. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.

Contact

Privacy Officer
Beeline Orthodontics
(704) 912-5234