Protected Health Information includes information that identifies you and relates to your past, present, or future physical or mental health, healthcare services, or payment for those services.

We are required by law to protect the privacy of your protected health information (“medical information”). We are also required to send you this notice about our privacy practices, our legal duties and your rights concerning your medical information.

We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect on the date set forth at the top of this page and will remain in effect unless we replace it.  We reserve the right at any time 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 any change in our privacy practices and the new terms of our notice applicable to all medical information we maintain, including medical information we created or received before we made the change in practices.

We may amend the terms of this notice at any time. If we make a material change to our policy practices, we will provide to you, the revised notice. Any revised notice will be effective for all health information we maintain. The effective date of a revised notice will be noted. A copy of the current notice in effect will be available in our facility and on our website. You may request a copy of the current notice at any time.  We collect and maintain oral, written and electronic information to administer our business and to provide products, services and information of importance to our patients. We maintain physical, electronic and procedural safeguards in the handling and maintenance of our patients’ medical information, in accordance with applicable state and federal standards, to protect against risks such as loss, destruction and misuse.

HOW WE MAY USE AND DISCLOSE YOUR INFORMATION

We may use and disclose your protected health information for the following purposes without your written authorization:

1. Treatment
We may disclose your medical information, without your prior approval, to another dentist or healthcare provider working in our facility or otherwise providing you treatment for the purpose of evaluating your health, diagnosing medical conditions and providing treatment. For example, your health information may be disclosed to an oral surgeon to determine whether surgical intervention is needed. 
2. Payment
We provide dental services. Your medical information may be used to seek payment from your insurance plan or from you. For example, your insurance plan may request and receive information on dates that you received services at our facility in order to allow your employer to verify and process your insurance claim. 
3. Healthcare Operations
We may use and disclose your medical information, without your prior approval, for health care operations. Health care operations include:

• Healthcare quality assessment and improvement activities;
• Reviewing and evaluating dental care provider performance, qualifications and competence, health care training programs, provider accreditation, certification, licensing and credentialing activities;
• Conducting or arranging for medical reviews, audits and legal services, including fraud and abuse detection and prevention; and
• Business planning, development, management and general administration including customer service, complaint resolutions and billing, de-identifying medical information, and creating limited data sets for health care operations, public health activities and research.

We may disclose your medical information to another dental or medical provider or to your health plan subject to federal privacy protection laws, as long as the provider or plan has had a relationship with you and the medical information is for that provider’s or health plan’s care quality assessment and improvement activities, competence and qualification evaluation and review activities, or fraud and abuse detection and prevention.

Your Authorization: You (or your legal personal representative) may give us written authorization to use your medical information or to disclose it to anyone for any purpose. Once you give us authorization to release your medical information, we cannot guarantee that the person to whom the information is provided will not disclose that information. You may take back or “revoke” your written authorization at any time, except if we have already acted based on your authorization. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. Unless you give us written authorization, we will not use or disclose your medical information for any purpose other than those described in this notice. We will obtain your authorization prior to using your medical information for marketing, fundraising purposes or for commercial use. Once authorize, you may opt out of these communications at any time.

Family, Friends and Others involved in your care or payment for care: We may disclose your medical information to a family member, friend or any other person you involve in your care or payment for your health care. We will disclose the medical information that is relevant to the person’s involvement.

We may use or disclose your name, location and general condition to notify, or to assist an appropriate public or private agency to locate and notify, a person responsible for your care in appropriate situations, such as a medical emergency or during disaster relief efforts.
We will provide you with an opportunity to object to these disclosures, unless you are not present or are incapacitated or it is an emergency or disaster relief situation. In those situations, we will use our professional judgment to determine whether disclosing your medical information is in your best interest under the circumstances.

Health-Related Products and Services: We may use your medical information to communicate with you about health-related products, benefits, services, payment for those products and services and treatment alternatives.

Reminders: We may use or disclose medical information to send you reminders about your dental care, such as appointment reminders via US Mail, email and telephone.  By providing your email address to us, you agree that you may receive reminders and breach notifications via email as a possible alternative to US Mail.  It is the policy of our office to leave a message on any voicemail or answering machine that may be attached to a number that you provide (home, cell or work).  If you prefer that we NOT leave a message to confirm treatment or your appointments, please check this box.

Plan Sponsors: If your dental insurance coverage is through an employer’s sponsored group dental plan, we may share summary health information with the plan sponsor.
Public Health and Benefit Activities: We may use and disclose your medical information, without your permission, when required by law and when authorized by law for the following kinds of public health and public benefit activities;

• For public health, including to report disease and vital statistics, child abuse, adult abuse, neglect or domestic violence;
• To avert a serious an imminent threat to health or safety;
• For health care oversight, such as activities of state insurance commissioners, licensing and peer review authorities and fraud prevention agencies;
• For research;
• In response to court and administrative orders and other lawful process;
• To law enforcement officials with regard to crime victims and criminal activities;
• To coroners, medical examiners, funeral directors and organ procurement organizations;
• To the military, to federal officials for lawful intelligence, counterintelligence, and national security activities, and to correctional institutions and law enforcement regarding persons in lawful custody; and
• As authorized by state worker’s compensation laws.

Special protections for SUD records: Substance Use Disorder (SUD) Treatment records have enhanced protections. They cannot be used in legal proceedings without your consent or court order.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.

Business Associates: We may disclose your medical information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
Data Breach Notification Purposes: We may use your contact information to provide legally required notices of unauthorized acquisition, access or disclosure of your health information.

Additional Restrictions on use and disclosure: Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly Confidential Information” may include confidential information under Federal laws governing reproductive rights, alcohol and drug abuse information and genetic information as well as state laws that often protect the following types of information:

1) HIV/AIDS;
2) Mental Health;
3) Genetic Tests (in accordance with GINA 2009);
4) Alcohol and drug abuse;
5) Sexually transmitted diseases and reproductive health information; and
6) Child or adult abuse or neglect, including sexual assault. 

OTHER PERMITTED OR REQUIRED USES AND DISCLOSURES

We may also use or disclose your protected health information in the following situations:

• As Required by Law: We may disclose information when required to do so by federal law, Georgia state law, or local regulations.
• Public Health Activities: As permitted by law, including reporting diseases, adverse reactions, product recalls, or notifying appropriate government authorities of suspected abuse, neglect, or domestic violence in accordance with Georgia law.
• Health Oversight Activities: For audits, investigations, inspections, licensure, or disciplinary actions authorized by law, including those conducted by Georgia regulatory agencies.
• Judicial and Administrative Proceedings: In response to a court order, subpoena, discovery request, or other lawful process as permitted under Georgia and federal law.
• Workers’ Compensation: To comply with workers’ compensation and similar programs established by Georgia law.
• Law Enforcement: As required or permitted by federal or Georgia law, including reporting certain types of wounds or assisting in locating a suspect, fugitive, or missing person.

USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION

We will obtain your written authorization before using or disclosing your protected health information for purposes not described in this Notice, including:

• Marketing communications not related to your care
• Certain disclosures of psychotherapy notes (if applicable)
• Substance Use Disorder records.
• Reproductive health records.

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

BILLING PRACTICES & OVERBILLING CONCERNS

We strive to bill accurately and transparently. However, billing disputes may occasionally occur due to insurance processing, coding changes, or payment adjustments.

• You have the right to request an explanation of charges billed to you or your insurance.
• You may dispute charges you believe are incorrect or excessive.
• Any billing concerns should be reported to our office promptly so we may investigate and resolve the issue.
• Overpayments identified by our office will be corrected and refunded in accordance with applicable federal and Georgia state laws.
• Insurance is an estimate, not a guarantee
• Patient responsibility for balances

Billing disputes do not affect your right to receive care, nor will you be retaliated against for raising concerns.

GOOD FAITH ESTIMATE (NO SURPRISES ACT)

Under the No Surprises Act, patients who do not have dental insurance or who choose not to submit a claim to their insurance have the right to receive a Good Faith Estimate of expected charges for dental services.

• The Good Faith Estimate provides an estimate of the costs for scheduled non-emergency services.
• The estimate is not a guarantee and may change if your treatment plan changes or if additional services are required.
• You may request a Good Faith Estimate at any time before services are provided.
• If your final bill is substantially higher than your Good Faith Estimate (generally $400 or more), you have the right to dispute the charges through the U.S. Department of Health and Human Services.

PAYMENT RESPONSIBILITY

You are responsible for all charges not covered by your insurance, including deductibles, co-payments, non-covered services, and balances remaining after insurance processing.
Insurance estimates are not a guarantee of payment. Final patient responsibility is determined by your insurance carrier.

BILLING QUESTIONS, COMPLAINTS & DISPUTES

If you have questions about your bill, believe you were overbilled, or wish to request a Good Faith Estimate, please contact our office directly:
Billing Contact:
Name/Title: Laura Chafin / Financial Coordinator
Phone: 678-762-1601
Email: [email protected]
You may also file a complaint regarding billing or privacy concerns with the U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint.
Reproductive Rights
We may document and maintain but we will never share with anyone without your written consent or a court order.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the following rights under HIPAA:

• Right to Access: You may inspect or obtain a copy of your dental and billing records, with limited exceptions. Requests must be made in writing.
• Right to Amend: You may request an amendment to your records if you believe information is incorrect or incomplete.
• Right to an Accounting of Disclosures: You may request a list of certain disclosures we have made of your protected health information.
• Right to Request Restrictions: You may request restrictions on how we use or disclose your information. We are not required to agree to all requests but will comply with any agreed restrictions.
• Right to Request Confidential Communications: You may request that we communicate with you in a specific way or at a specific location (e.g., only at work, by email, or by mail).
• Right to a Paper Copy: You may request a paper copy of this Notice at any time, even if you have agreed to receive it electronically.
• Right to restrict: You have a right to restrict who receives your information.
• Right to complain: See below information.

BREACH NOTIFICATION

You have the right to be notified if a breach of your unsecured protected health information occurs, as required by law.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint.

Privacy Officer:
Name/Title: Jennifer Mollison / HIPAA officer
Phone: 678-762-1601
Email: [email protected]
HHS Contact:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, SW, Room 509F, Washington, DC, 20201
www.hhs.gov/ocr
(800) 368-1019