THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS DOCUMENT CAREFULLY. THE PRIVACY OF YOUR PERSONAL HEALTH INFORMATION IS VERY IMPORTANT TO US.

OUR LEGAL OBLIGATION
Lake Mary Family Dentistry is required by applicable federal and state laws to maintain the privacy of your personal health information (“PHI”). It is mandatory that you are provided with this Notice of Privacy Practices describing our privacy practices and legal duties, in addition to your rights regarding your health information. The privacy practices described in this Notice will be adhered to while it is in effect. This updated Notice takes effect April 24, 2023, and will remain in place until any future updates.

Lake Mary Family Dentistry reserves the right to alter our privacy practices at any time. Any alterations would be included in a future updated Notice. If substantial updates are made to the Notice, an electronic copy will be provided to you along with dated notification of when the changes will occur via email. The updated Notice will then apply to any previous or newly obtained PHI as of the new effective Notice date.

The current version of this Notice will also be available on the website www.lakemaryfamilydentistry.com for access. A copy may be requested at any time. Physical copies available on site at the office. Please refer to the contact information at the end of this Notice for more information or to request a copy.

USES AND DISCLOSURES OF HEALTH INFORMATION THAT DO NOT REQUIRE AN AUTHORIZATION

Treatment: We may disclose your PHI to a physician or other health care provider providing treatment to you. This includes Pharmacies as well as dental specialists such as Periodontists, Endodontists and Oral Surgeons. This is to provide the best available patient care.

Payment: We may use and disclose your PHI to obtain payment for services provided to you by this practice. This includes insurance providers and other third party payers.

Healthcare Operations: We may use and disclose your PHI in connection to practice healthcare operations. As examples, healthcare operations include but not limited to quality assessment and improvement activities, evaluation of practitioner and provider performance, accreditation, certification, and licensing and credentialing activities.

Business Associates: We may share your PHI with third party business associates. Some examples include answering services, billing services, consultants and legal counsel. When these business relations exist, the office will obtain a written agreement between the Practice and the business associate to assure the protection and privacy of your PHI.

Communication with You: The practice may use and disclose your PHI to provide you with a reminder for your appointments. This reminder may come in the form of direct mail, such as a letter or postcard. Most reminders are now done either electronically via email or by phone or text.

Upon Your Request / Permission: At any time, you may notify the practice in writing that it is appropriate to share PHI with another party per your request. Additionally, an option to share intraoral photography with no direct personal identification to assist other patients is available in the new patient paperwork.

Individuals Involved in Care: If necessary, we may disclose your PHI to a family member, friend, or other person identified by you as being responsible for your health care. If you are not present, professional judgment will be used to determine what is the best course of action.

Other Uses and Disclosures:
• Required by Law: PHI may be disclosed when required by law.
• Abuse / Neglect: PHI may be disclosed and authorities may be contacted if some form of abuse or neglect is reasonably to be believed. PHI may be disclosed to the extent as to avoid further serious harm or threat to you or others.
• Public Health Activities: PHI may be disclosed to allow public health investigations
• National Security: We may disclose to authorized federal officials PHI required for lawful intelligence, counterintelligence, and other national security activities. The PHI of Armed Forces personnel may be disclosed under certain circumstances.
• Coroners, Medical Examiners and Funeral Directors: PHI may be disclosed in the event of a request from a coroner, medical examiner or funeral director.

YOUR RIGHTS

Access to your PHI: Outside of some exceptions, you have the right to inspect or obtain copies of your PHI. Since your PHI is stored in electronic format, we will attempt to supply your PHI in the form that your request. If you request your PHI as paper copies, a nominal fee will be charged to produce it. Please contact the office at the contact information for current fees. Requests for PHI must be received in written form. Requests will normally be honored within 10 business days of receipt.

Disclosure Accounting: You have the right to receive a list of occurrences in which we or our business associates disclosed your health information for reasons other than payment, treatment, healthcare operations and certain other activities. The time period available is the last 6 years or such shorter time as you may specify. If this request is made more than once in a 12 month period, a reasonable, cost-based fee may be charged to respond to the request.

Restrictions: You have the right to request additional restrictions on the use or disclosure of your PHI. This request should be in the form of a written notification. We are not required to honor all requests.

Alternative Communications: You have the right to request that we communicate with you about your PHI by alternative means or to alternative locations. Use the contact information at the end of this Notice to contact the office to update this information. All reasonable requests will be accommodated.

Amendment: You have the right to request an amendment to your PHI. This request must be received in writing, including an explanation for the request. Most requests will be honored within 10 business days. The office, however, does have the discretion of denying your request in certain circumstances.

Electronic / Paper Notice: If you receive this notice electronically, via email or website, you have the right to a physical paper copy. Please contact the office at the contact information below to make arrangements to receive a physical copy.

CONTACT INFORMATION
If you have any questions about this Notice, you may contact us at the below:
Contact Officer: Grant Pinney, DMD
Telephone: (407) 862-3344
Fax: (407) 862-3374
E-mail: office@lakemaryfamilydentistry.com
Address: 1325 S. International Parkway, Suite 1201, Lake Mary, Florida 32746

COMPLAINTS
If you are concerned that your privacy rights have been violated, you may file a complaint with us using the contact information above.

You can also file a written complaint to the U.S. Department of Health and Human Services in Washington, DC. We will provide you with the address to file your complaint upon request. As we value your privacy of your health information, no retaliation will occur against you for your complaint.