Effective [OFFICE TO CONFIRM: effective date] · Privacy contact: [OFFICE TO CONFIRM: Privacy Officer name or title], (407) 850-0133, 2067 Americana Blvd, Orlando, FL 32839
Your rights
When it comes to your health information, you have the right to:
- Get a copy of your dental and billing records, on paper or electronically. We will usually provide it within 30 days and may charge a reasonable, cost-based fee.
- Ask us to correct information you think is wrong or incomplete. We may say no, but we will tell you why in writing within 60 days.
- Ask for confidential communications — for example, to be called on a different phone or mailed at a different address. We will say yes to all reasonable requests.
- Ask us to limit what we use or share. We are not required to agree, except: if you pay for a service in full out of pocket, you can ask us not to share it with your health insurer, and we will say yes unless the law requires us to share it.
- Get a list of those we have shared your information with for up to six years before your request, with some exceptions.
- Get a paper copy of this notice at any time, even if you agreed to get it electronically.
- Choose someone to act for you, such as a legal guardian or someone with medical power of attorney.
- File a complaint if you believe your rights were violated — see "Complaints" below.
Your choices
You can tell us whether to share information with family, close friends or others involved in your care or payment. If you cannot tell us (for example, if you are unconscious), we may share it if we believe it is in your interest. We never use your information for marketing, and never sell it, unless you give us written permission.
How we use and share your information
- Treatment — for example, sharing X-rays with another dentist or doctor we refer you to.
- Payment — billing you or your dental plan.
- Running our practice — quality checks, training, and appointment reminders.
- Other ways the law allows or requires, under strict conditions: public health and safety, reporting suspected abuse or neglect, health oversight, lawsuits and legal orders, law enforcement, workers' compensation, coroners and medical examiners, organ donation, research, special government functions, and responding to government requests.
Other uses and disclosures not described here will be made only with your written permission, which you can take back in writing at any time.
Our responsibilities
- We are required by law to keep your protected health information private and secure.
- We will tell you promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow this notice and give you a copy. We can change it; the new notice will apply to all information we have, and will be posted in our office and on this website.
[OFFICE TO CONFIRM: attorney to add any Florida-law additions (e.g. patient-records rules under s. 466.018 and s. 456.057, F.S.) and, if applicable, the Part 2 substance-use-disorder record statements.]
Complaints
You can complain to us: [OFFICE TO CONFIRM: Privacy Officer], Americana Family Dental, 2067 Americana Blvd, Orlando, FL 32839, (407) 850-0133.
You can also complain to the U.S. Department of Health and Human Services Office for Civil Rights: 200 Independence Avenue SW, Washington, D.C. 20201; 1-877-696-6775; www.hhs.gov/ocr/complaints. We will not retaliate against you for filing a complaint.