HIPAA Notice of Privacy Practices

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

Who We Are

This Notice describes the privacy practices of Arati Shrestha, DMD, PLLC, doing business as Amity Dentistry (“we,” “us,” or “our practice”), located at 7221 Pineville-Matthews Rd, Ste 100, Charlotte, NC 28226. It applies to all records of your care created or maintained by our practice.

Our Legal Duty

We are required by law to maintain the privacy of your protected health information (PHI), to give you this Notice of our legal duties and privacy practices, to follow the terms of the Notice currently in effect, and to notify you if a breach of your unsecured PHI occurs.

How We May Use and Disclose Your Health Information

Treatment. We use and share your health information to provide, coordinate, and manage your dental care — for example, sharing X-rays or treatment records with an oral surgeon, orthodontist, or other specialist involved in your care.

Payment. We use and share your information to bill and collect payment for services — for example, submitting claims to your dental insurance, verifying benefits, or processing statements.

Health Care Operations. We may use your information to run our practice — quality review, training, scheduling, and similar administrative activities.

Appointment Reminders and Communications. We may contact you by phone, text message, email, or mail to remind you of appointments, share treatment options, or tell you about services that may benefit you. See our SMS Policy and Communications Consent for details. You may ask us to communicate with you in a different way or at a different location.

Business Associates. We may share your information with contractors who perform services for us (for example, billing services, IT vendors, or a dental laboratory). They are required by law and by contract to safeguard your information.

Family and Friends. We may share relevant information with a family member or friend involved in your care or in payment for your care, if you agree or, in an emergency, when it is in your best interest.

As Required by Law and for Public Health and Safety. We will share information when federal or state law requires it, including: reporting suspected abuse or neglect; public health reporting (such as communicable disease); reporting to the FDA regarding products; and preventing a serious threat to health or safety.

Health Oversight, Legal Proceedings, and Law Enforcement. We may disclose information to health oversight agencies (audits, licensure), in response to a court order, subpoena, or other lawful process, and to law enforcement as permitted by law.

Other Permitted Disclosures. These include disclosures to coroners, medical examiners, and funeral directors; for organ and tissue donation; for approved research; for specialized government functions such as military or national security; and for workers’ compensation claims.

Uses and Disclosures That Require Your Written Authorization

We will not use or disclose your health information for marketing purposes, sell your health information, or share psychotherapy notes without your written authorization. Other uses and disclosures not described in this Notice will be made only with your written authorization. You may revoke an authorization at any time in writing, except to the extent we have already relied on it.

Your Rights Regarding Your Health Information

• Right to Inspect and Copy. You may request to see or receive a copy of your dental and billing records, including an electronic copy. We may charge a reasonable, cost-based fee.
• Right to Amend. If you believe information in your record is incorrect or incomplete, you may request an amendment in writing.
• Right to an Accounting of Disclosures. You may request a list of certain disclosures we have made of your information during the prior six years.
• Right to Request Restrictions. You may ask us to limit how we use or share your information. We are not required to agree, except that we must honor your request not to share information with your health plan about a service you (or someone on your behalf) paid for in full out of pocket.
• Right to Confidential Communications. You may ask us to contact you in a specific way or at a specific location (for example, cell phone only).
• Right to a Paper Copy. You may request a paper copy of this Notice at any time, even if you agreed to receive it electronically.
• Right to Breach Notification. You have the right to be notified if a breach of your unsecured health information occurs.
• Personal Representatives. If you have given someone medical power of attorney or someone is your legal guardian, that person may exercise your rights on your behalf.

Genetic Information

We will not use or disclose genetic information for underwriting purposes, as prohibited by the Genetic Information Nondiscrimination Act (GINA).

Changes to This Notice

We reserve the right to change this Notice and to make the revised Notice effective for information we already have as well as information we receive in the future. The current Notice is posted in our office and on our website with its effective date.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our Privacy Official using the contact information below, or with the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue S.W., Washington, D.C. 20201, phone 1-877-696-6775, or online at hhs.gov/ocr/privacy/hipaa/complaints. We will not retaliate against you for filing a complaint.

Contact Our Privacy Official

Privacy Official, Amity Dentistry
7221 Pineville-Matthews Rd, Ste 100, Charlotte, NC 28226
Phone: (980) 423-1244
Email: [email protected]