NOTICE OF PRIVACY PRACTICES 

Swauger & Suiter Pediatric Dentistry 

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOUR CHILD MAY BE USED  AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 

The privacy of your child’s health information is important to us. 

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We are required by law to maintain the privacy of protected health information, to provide individuals with  notice of our legal duties and privacy practices with respect to protected health information, and to notify  affected individuals following a breach of unsecured protected health information. We must follow the  privacy practices that are described in this Notice while it is in effect. This Notice takes effect September 1,  2022, 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, and to make new Notice provisions effective for all protected  health information that we maintain. When we make a significant change in our privacy practices, we will  change this Notice and post the new Notice clearly and prominently at our practice location, and we will  provide copies of the new Notice 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. ______________________________________________________________________________________ 

Use and Disclosure of Health Information 

We may use and disclose your health information for different purposes, including treatment, payment, and  health care operations. For each of these categories, we have provided a description and an example.  Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse  records, and mental health records may be entitled to special confidentiality protections under applicable  state or federal law. We will abide by these special protections as they pertain to applicable cases involving  these types of records. 

Tratamiento: We may use and disclose your health information for your treatment. For example, we may  disclose your health information to a specialist providing treatment to you. 

Pago: We may use and disclose your health information to obtain reimbursement for the treatment and  services you receive from us or another entity involved with your care. Payment activities include billing,  collections, claims management, and determinations of eligibility and coverage to obtain payment from  you, an insurance company, or another third party. For example, we may send claims to your dental health  plan containing certain health information. 

Healthcare Operations: We may use and disclose your health information in connection with our  healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities. 

Individuals Involved in Your Care or Payment for Your Care: We may disclose your health  information to your family or friends or any other individual identified by you when they are involved in  your care or in the payment for your care. Additionally, we may disclose information about you to a patient  representative. If a person has the authority by law to make health care decisions for you, we will treat that  patient representative the same way we would treat you with respect to your health information. 

Asistencia en casos de catástrofe: We may use or disclose your health information to assist in disaster relief efforts.

Required by Law: We may use or disclose your health information when we are required to do so by law. 

Public Health Activities: We may disclose your health information for public health activities, including  disclosures to: 

• Prevent or control disease, injury or disability; 

• Report child abuse or neglect; 

• Report reactions to medications or problems with products or devices; 

• Notify a person of a recall, repair, or replacement of products or devices; 

• Notify a person who may have been exposed to a disease or condition; or 

• Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect,  or domestic violence. 

National Security: We may disclose to military authorities the health information of Armed Forces  personnel under certain circumstances. We may disclose to authorized federal officials health information  required for lawful intelligence, counterintelligence, and other national security activities. We may disclose  to correctional institution or law enforcement official having lawful custody the protected health  information of an inmate or patient. 

Secretary of HHS: We will disclose your health information to the Secretary of the U.S. Department of  Health and Human Services when required to investigate or determine compliance with HIPAA. 

Worker’s Compensation: We may disclose your PHI to the extent authorized by and to the extent  necessary to comply with laws relating to worker’s compensation or other similar programs established by  law. 

Law Enforcement: We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as  required by law, or in response to a subpoena or court order. 

Health Oversight Activities: We may disclose your PHI to an oversight agency for activities authorized  by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary  for licensure and for the government to monitor the health care system, government programs, and  compliance with civil rights laws. 

Judicial and Administrative Proceedings: If you are involved in a lawsuit or a dispute, we may disclose  your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in  the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the  request or to obtain an order protecting the information requested. 

Research: We may disclose your PHI to researchers when their research has been approved by an  institutional review board or privacy board that has reviewed the research proposal and established  protocols to ensure the privacy of your information. 

Coroners, Medical Examiners, and Funeral Directors: We may release your PHI to a coroner or  medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them  to carry out their duties. 

Fundraising: We may contact you via mail, email and text messages to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do  not wish to receive such information from us, you may opt out of receiving the communications. 

Other Uses and Disclosures of PHI: Your authorization is required, with a few exceptions, for disclosure  of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain  your written authorization before using or disclosing your PHI for purposes other than those provided for in  this Notice (or as otherwise permitted or required by law). You may revoke an authorization in writing at 

any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the  extent that we have already taken action in reliance on the authorization. 

______________________________________________________________________________________ Your Health Information Rights 

Access: You have the right to look at or get copies of your health information, with limited exceptions.  You must make the request in writing. You may obtain a form to request access by using the contact  information listed at the end of this Notice. You may also request access by sending us a letter to the  address at the end of this Notice. If you request information that we maintain on paper, we may provide  photocopies. If you request information that we maintain electronically, you have the right to an electronic  copy. We will use the form and format you request if readily producible. Contact us using the information  listed at the end of this Notice for an explanation of our fee structure. If you are denied a request for access,  you have the right to have the denial reviewed in accordance with the requirements of applicable law. 

Disclosure Accounting: With the exception of certain disclosures, you have the right to receive an  accounting of disclosures of your health information in accordance with applicable laws and regulations.  To request an accounting of disclosures of your health information, you must submit your request in  writing to the Privacy Official. 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 the additional requests. 

Right to Request a Restriction: You have the right to request additional restrictions on our use or  disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must  include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both,  and (3) to whom you want the limits to apply. We are not required to agree to your request except in the  case where the disclosure is to a health plan for purposes of carrying out payment or health care operations,  and the information pertains solely to a health care item or service for which you, or a person on your  behalf (other than the health plan), has paid our practice in full. 

Alternative Communication: You have the right to request that we communicate with you about your  health information by alternative means or at alternative locations. You must make your request in writing.  Your request must specify the alternative means or location, and provide satisfactory explanation of how  payments will be handled under the alternative means or location you request. We will accommodate all  reasonable requests. However, if we are unable to contact you using the ways or locations you have  requested we may contact you using the information we have. 

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. If we agree to your request, we will amend your record(s) and notify you of such. If  we deny your request for an amendment, we will provide you with a written explanation of why we denied  it and explain your rights. 

Right to Notification of a Breach: You will receive notifications of breaches of your unsecured protected  health information as required by law. 

Electronic Notice: You may receive a paper copy of this Notice upon request, even if you have agreed to  receive this Notice electronically on our Web site or by electronic mail (email). 

______________________________________________________________________________________ Questions and Complaints 

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 if 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. 

Our Privacy Official: Michael Dearry, Office Manager 

Telephone: 615-868-9057

Fax: 615-868-0234 

Address:  

Madison Office: 500 Lentz Drive, Suite 40, Madison, TN 37115 

Hendersonville Office: 118 Maple Row Blvd, Suite A1A, Hendersonville, TN 37075

Email: michael@krspd.com

Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any other party  requires the prior written approval of the American Dental Association. This material is for general reference purposes only and does  not constitute legal advice. It covers only HIPAA , not other federal or state law. Changes in applicable laws or regulations may  require revision. Dentists should contact qualified legal counsel for legal advice, including advice pertaining to HIPAA compliance,  the HITEC H Act, and the U.S. Department of Health and Human Services rules and regulations. 

© 2010, 2013 American Dental Association. All Rights Reserved.

Updated February 2021