HIPAA Notice of Privacy Practices

Effective: September 13, 2016

Revised: July 9, 2024

TOMHAVE DENTAL ASSOCIATES

1211 Stanley Avenue

Cloquet, MN 55720

(218) 879-4541

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

This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how Tomhave Dental Associates and their subcontractors, may use and disclose your Protected Health Information (PHI) to conduct treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI. PHI is information about you, including demographic information, which may identify you and relates to your past, present or future physical or mental health condition and related health care services. We respect our obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This notice describes how we protect your health information and what rights you have regarding it. 

USES AND DISCLOSURES OF PHI

Your PHI may be used and disclosed by your dentist, our office staff, and others outside our office involved in your care and treatment for the purpose of providing health care services to you, to pay your dental care bills, to support the operation of Tomhave Dental Associates, and any other use required by law. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:

https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html  

Treatment: We may use and disclose your PHI to provide, coordinate, or manage your dental care and any related services. This includes the coordination or management of your health care with a third party. For example, your PHI may be provided to a referring dental specialist to ensure they have the necessary information to diagnose or treat you.  

Payment: Your PHI is used to obtain payment for your dental care services. For example, obtaining approval for any procedure/treatment may require your relevant PHI be disclosed to the dental/health plan to obtain approval for the work.  

Healthcare Operations: We may use a sign-in sheet at the registration desk where you may be asked to sign your name and indicate your doctor/health information. We may also call you by name in the waiting room when your dentist/hygienist is ready to see you. We may use or disclose your PHI to remind you of your appointment and inform you about treatment alternatives or other health-related benefits and services which may be of interest to you.  

OUR RESPONSIBILITIES

We are required by law to maintain the privacy and security of your protected health information. We may use or disclose your PHI in the following situations without your authorization. These situations include public health issues as required by law, health research, communicable diseases, health oversight, if unconscious and we believe it is in your best interest, helping with product recalls, reporting adverse reactions to medications, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, criminal activity, military activity and national security, workers’ compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your PHI when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under 45 CFR §164.500.

USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION

Other Permitted and Required Uses and Disclosures occur only with your consent, authorization or opportunity to object unless required by law. Use or disclosure of your PHI for marketing purposes or fundraising is prohibited, without your authorization. We may not sell your PHI without your authorization. You may revoke the authorization, at any time, in writing, except to the extent that your dentist or Tomhave Dental Associates has taken an action in reliance on the use or disclosure indicated in the authorization.  

YOUR RIGHTS

You have the right to inspect and copy your PHI (fees may apply) – Pursuant to your written request, you have the right to inspect or copy your PHI by electronic format. We will provide a copy or a copy summary of your health information, usually within 30 days of your request. Under federal law, however, you may not inspect or copy the following records: Information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, PHI restricted by law, information related to medical research in which you have agreed to participate, information may result in harm or injury to you or to another person, or information obtained under a promise of confidentiality.  

You have the right to request a restriction of your PHI – This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment, or healthcare operations. You may also request any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your dentist is not required to agree to your requested restriction except if you request the dentist not disclose PHI to your dental/health plan with respect to health care for which you have paid in full out-of-pocket.  

You have the right to request confidential communications – You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, for example electronically.  

You have the right to request an amendment to your PHI – If we deny your request for amendment, you have the right to file a statement of disagreement. However, we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.  

You have the right to 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.  

You have the right to receive an accounting of certain disclosures – You have the right to receive an accounting of disclosures, paper or electronic, except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, occurring six years prior to the date of the request.  

You have the right to receive notice of a breach – we will notify you if your unsecured PHI has been breached.  

You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically. Tomhave Dental Associates reserves the right to change the terms of this notice and will notify you of such changes on the following appointment. Copies of the new notice will be available upon request.  

COMPLAINTS

Tomhave Dental Associates will not retaliate against you for filing a complaint. If you believe your privacy rights have been violated, please notify Tomhave Dental Associates by calling (218)-879-4541. You may file a complaint with the Office of Civil Rights (OCR) by submitting your written complaint and mailing it to: Centralized Case Management Operations U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201, or calling (800) 368-1019,  TDD: (800)-537-7697, or filing a complaint online via:

https://www.hhs.gov/hipaa/filing-a-complaint/what-to-expect/index.html  

Tomhave Dental Associates is required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of the notice currently in effect. If you have any questions about this form, please ask to speak with our HIPAA Compliance Officer in person or by phone. Please sign the accompanying “Acknowledgment” form. Please note by signing the Acknowledgment form you are only acknowledging you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices.