Middleton Family Dentistry
Effective Date: January 1, 2025
Last Updated: January 1, 2025
THIS NOTICE DESCRIBES HOW YOUR PROTECTED HEALTH INFORMATION (PHI) MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Our Commitment to Your Privacy
Middleton Family Dentistry values your privacy and is committed to protecting your health information. As required by the Health Insurance Portability and Accountability Act (HIPAA) and other applicable laws, we are required to:
- Maintain the privacy of your Protected Health Information (PHI).
- Provide this Notice of Privacy Practices outlining our legal duties and privacy practices.
- Follow the terms of this Notice while it is in effect.
We reserve the right to amend our privacy practices and the terms of this Notice. Any changes will apply to all PHI that we maintain, and we will make updated copies of this Notice available upon request.
For questions or concerns about this Notice, please contact us using the information below.
How We Use and Disclose Your Health Information
We may use and disclose your PHI for the following purposes:
1. Treatment, Payment, and Healthcare Operations
- Treatment: We may share PHI with dentists, specialists, or other healthcare providers involved in your care.
- Payment: We may use or disclose your PHI to process insurance claims, receive payment for services, and provide billing details to you or third parties responsible for your healthcare costs.
- Healthcare Operations: We may use your PHI for quality assessment, staff training, licensing, and other internal operations to improve the quality of care.
2. Your Authorization
You may authorize us to use or disclose your PHI for purposes other than treatment, payment, and healthcare operations. You may revoke your authorization in writing at any time.
3. Family, Friends, and Caregivers
We may disclose your PHI to family members, caregivers, or other persons involved in your care if you provide consent or in medical emergencies where your consent cannot be obtained.
4. Required or Permitted by Law
We may disclose your PHI without your authorization when required by law, including:
- Public Health & Safety: Reporting communicable diseases, adverse drug reactions, or abuse/neglect cases.
- Law Enforcement & Legal Proceedings: Compliance with subpoenas, court orders, and investigations.
- Health Oversight Activities: Audits, inspections, and compliance with regulatory agencies.
- Workers’ Compensation: Processing claims related to workplace injuries.
- National Security & Military Purposes: If you are in the military or involved in intelligence activities.
5. Appointment Reminders & Communications
Unless you request otherwise, we may use your PHI to remind you of upcoming appointments via phone, text, email, or postcards.
6. Marketing & Fundraising Communications
Without your written authorization, we will not use or share your PHI for marketing purposes. You may opt-out of any marketing communications.
Your Rights Regarding Your Health Information
As a patient, you have the following rights under HIPAA:
1. Right to Access & Copies
You may request to inspect or obtain copies of your PHI. We may charge a reasonable fee for copying and mailing records.
2. Right to Amend Your Records
If you believe your records contain errors, you may request a correction. We may deny requests in some instances but will provide a written explanation.
3. Right to Request Restrictions
You may request restrictions on how we use or share your PHI. We are not required to agree to all restrictions, but we will accommodate reasonable requests where possible.
4. Right to Confidential Communications
You may request that we contact you via an alternative method (e.g., mailing to a P.O. box instead of your home). We will comply with reasonable requests.
5. Right to Accounting of Disclosures
You may request a list of instances where we disclosed your PHI outside of treatment, payment, and healthcare operations in the past six years.
6. Right to Receive an Electronic or Paper Copy of This Notice
You can obtain a copy of this Notice in paper or electronic format anytime.
Protecting Your Health Information
We follow strict security protocols to protect your PHI, including:
- Encryption and Secure Storage: Ensuring PHI is stored securely.
- Access Controls: Limiting who can access your records.
- HIPAA Compliance Training: Educating staff on patient privacy.
Despite our best efforts, no transmission over the internet is 100% secure. Please take precautions when sharing sensitive health information electronically.
Filing A Complaint
If you believe we have violated your privacy rights, you may file a complaint with:
Middleton Family Dentistry
East State Boulevard Location
4302 East State Blvd, Fort Wayne, IN 46815 – (260) 484-3136
New Dupont Road Location
5050 Great Oak Ct, Fort Wayne, IN 46825 – (260) 490-3495
Email: office@middletondentistry.com
Website: https://middletondentistry.com
OR
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
Toll-Free: 1-800-368-1019
Website: www.hhs.gov/ocr/privacy/hipaa/complaints
We will not retaliate against you for filing a complaint.
Acknowledgment of Receipt
We ask all patients to sign an acknowledgment form confirming they have received this Notice of Privacy Practices. A copy will be kept in your patient file.
Updates to this Notice
We may update this Notice periodically. Any changes will be posted on our website and made available upon request.