1311 Jackson Ave Dental
Notice of Privacy Practices
Long Island City, NY 11101.

This notice describes how medical information about you may be used and disclosed.

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This notice describes the privacy practices of 1311 Jackson Ave Dental. "We" and "our" means the dental office 1311 Jackson Ave Dental. "You" and "your" means all of our patients.

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The privacy of your health information is very important to us and we are committed to protecting it. This notice describes how we may use and disclose your protected health information so that we can carry out treatment, payment, and other health care operations that are permitted/required by law. Your protected health information includes demographic information that may identify you whether it be your past, present, or future state.

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Requirements by law:

• Maintain the privacy of your protected health information

• Give you this notice of our legal duties and privacy practices

• Uphold and abide by the terms of our notice

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How we may use or disclose your protected health information.

These are some common uses:

• Treatment - We use your health information so that we may provide you with dental treatment. We may also disclose your information to other healthcare professionals such as dental specialists and physicians, who may be involved in your care.

• Payment - We use your health information to file claims on your behalf from your insurance companies in order to obtain payment.

• Health care operations - We use your information for health care operations necessary to run our practice. Treatment, services, training, quality assurance, financial matters, legal matters, and business development.

• Appointment reminders - We may contact you by using mail, phone calls, text messages, and emails.

• Treatment alternatives and health related benefits and services - We may use your information to tell you about treatment options and alternative treatment options which may be of interest to you.

• Disclosure to certain family members and friends - We may disclose your information to any person that is involved in your care or payment. You may choose to opt out.

• Disclosure to Business associates - We may disclose your information to third-party service providers such as "Business associates" who function on behalf of our office. All of our business associates are under contract to not disclose your information outside of the scope of our relationship.

These are some less common uses:

• Disclosures required by Law - We are required to disclose your information to the US Department of health and human services so that it can investigate complaints or determine our compliance with HIPAA.

• Public Health Activities - Information may be disclosed for public health purposes such as: controlling disease, injury, disability, reporting births/deaths, child abuse, child neglect, adverse reactions to medications, adverse reactions to foods, product defects, product recalls, and etc.

• Victims of Abuse, Neglect, or Domestic Violence - We are obligated to disclose information to the appropriate government authority about any patient whom we may believe is a victim.

• Health Oversight Activities - We may disclose information to government associated health oversight agencies for the health care system, benefit programs, and civil rights laws.

• Lawsuits and Legal Actions - Information may be disclosed in response to a court/administrative order or subpoena, discovery request, or other lawful processes.

• Law Enforcement Purposes - Information may be disclosed to law enforcement officials for law enforcement purposes such as for identifying persons of interest.

• Coroners, Medical Examiners, and Funeral Directors - We may disclose information in order for the above to carry out their duty.

• Organ, Eye, and Tissue Donations - We may disclose your information for organ procurement organizations or others that obtain them.

• Research Purposes - We may disclose information for research purposes pursuant to patient authorization waiver approval by an Institutional Review board or Privacy Board.

• Serious Threat to health/Safety - We may disclose your health information if we believe it is necessary to minimize harm to others.

• Specialized Government Functions - We may disclose your protected health information to the military about its members for national security and protective services for the President and other heads of state, to the government for security clearance reviews. We may also disclose to prisons about inmates.

• Workers Compensation - Your information may be disclosed to comply with worker's compensation laws that provide benefits for work related injuries or illnesses.

• Your Written Authorization for any other uses or disclosures - Other uses and disclosures will only be made with your written authorization. This authorization may be revoked at any time with written consent.

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Your Rights with Respect to Your Health Information

• To exercise any of these rights, simply submit a written request.

  • Right to Access and Review - You may request access to a copy of your health information. Although your request may be denied under certain circumstances and if it is you will receive a notice. Otherwise, your health information is stored electronically and you may direct us to send it to your destination of choice. We may charge a convenience fee if it is in a form other than electronic.

  • Right to Amend - You may request to have your information amended if you believe it to be erroneous.

  • Right to Restrict Use - You may request our office to restrict the disclosure of your protected health information to any individual. For example if you pay out of pocket in full for a service and you request us to not submit the claim to your insurance on your behalf.

  • Right to Confidential Communications, Alternative Means and Locations - You may request to receive communication about your health information via alternative means of your choice.

  • Right to an Accounting of Discolosures - You have the right to receive an accounting of disclosures of your health information for up to six years prior to the date of accounting disclosure request.

  • Right to a Paper Copy of this Notice - You may request us to print a paper copy of this notice or you may do so yourself.

  • Right to Receive Notification of a Security Breach - We are required by law to notify you if the privacy or security of your health information has been breached. The notification will be sent out via first class mail USPS within 60 days of occurrence. The breach notification will contain a brief description of what happened, the date it occurred, the steps you should take, and the steps we will take to mitigate the effects.

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Special Protections for HIV, Alcohol, and Substance Abuse, Mental Health and Genetic Information - Some parts of this HIPAA notice of privacy practices may not apply to some of these types of information due to certain federal and state laws.

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Our Right to Change Our Privacy Practices and This Notice

We reserve the right to change the terms of this Notice at any time. It will be posted here and updated as needed.

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How to Make Privacy Complaints

If you have any complaints about your privacy rights and the use of your protected health information, you may file a complaint with us. You may also file a written complaint with the secretary of the US department of health and human services, office for civil rights. We will not retaliate against you in any way if you choose to do so.

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We respect our legal obligation to keep health information that identifies you private. We are obligated
by law to give you notice of our privacy practices. This Notice describes how we protect your health
information and what rights you have regarding it.

TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
The most common reason why we use or disclose your health information is for treatment, payment or
health care operations. Examples of how we use or disclose information for treatment purposes are: setting
up an appointment for you; examining your teeth, mouth, and oral health; prescribing medications and
faxing them to be filled; prescribing dental appliances and dental prostheses; showing you treatment
options; referring you to another dentist for specialty care; or getting copies of your health information from
another professional that you may have seen before us. Examples of how we use or disclose your health
information for payment purposes are: asking you about your dental or medical care plans, or other sources
of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or
through a collection agency or attorney). “Health care operations” mean those administrative and
managerial functions that we have to do in order to run our office. Examples of how we use or disclose your
health information for health care operations are: financial or billing audits; internal quality assurance;
personal decisions; participation in managed care plans; defense of legal matters; business planning; and
outside storage of our records.

We routinely use your health information inside our office for these purposes without any special
permission. If we need to disclose your health information outside of our office for these reasons, (we will)
(we usually will not) ask you for special permission.

We will ask for special written permission in the following situations: anything related to HIV/AIDS status,
any sale of information, any use of information for marketing or fundraising purposes.
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

In some limited situations, the law allows or requires us to use or disclose your health information without
your permission. Not all of these situations will apply to us; some may never come up at our office at all.
Such uses or disclosures are:

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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.

SUD Treatment Information. If we receive or maintain any information about you from a
substance use disorder treatment program that is covered by 42 CFR Part 2 (a “Part 2 Program”)
through a general consent you provide to the Part 2 Program to use and disclose the Part 2
Program record for purposes of treatment, payment or health care operations, we may use and
disclose your Part 2 Program record for treatment, payment and health care operations
purposes as described in this Notice. If we receive or maintain your Part 2 Program record
through specific consent you provide to us or another third party, we will use and disclose your
Part 2 Program record only as expressly permitted by you in your consent as provided to us.
In no event will we use or disclose your Part 2 Program record, or testimony that describes the
information contained in your Part 2 Program record, in any civil, criminal, administrative, or
legislative proceedings by any Federal, State, or local authority, against you, unless authorized
by your consent or the order of a court after it provides you notice of the court order.

 when a state or federal law mandates that certain health information be reported for a specific
purpose;
 for public health purposes, such as contagious disease reporting, investigation or surveillance; and
notices to and from federal Food and Drug Administration regarding drugs or medical devices;
 disclosures to governmental authorities about victims of suspected abuse, neglect or domestic
violence;
 uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by
Medicare or Medicaid; or for investigation of possible violations of health care laws;
 disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders
of courts or administrative agencies;
 disclosures for law enforcement purposes, such as to provide information about someone who is or
is suspected to be a victim of a crime; to provide information about a crime at our office; or to
report a crime that happened somewhere else;
 disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to
funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
 uses or disclosures for health related research;
 uses and disclosures to prevent a serious threat to health or safety
 uses or disclosures for specialized government functions, such as for the protection of the president
or high ranking government officials; for lawful national intelligence activities; for military purposes;
or for the evaluation and health of members of the foreign service;
 discloses of de-identified information;
 disclosures relating to worker’s compensation programs;
 disclosures of a “limited data set” for research, public health, or health care operations;
 incidental disclosures that are unavoidable by-product of permitted uses or disclosures;

 disclosures to “business associates” who perform health care operations for us and who commit to
respect the privacy of your health information.

APPOINTMENT REMINDERS
We may call or write or text to remind you of scheduled appointments, or that it is time to make a routine
appointment. We may also call or write to notify you of other treatments or services available at out office
that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a postcard,
and/or leave you a reminder message on your home answering machine or with someone who answers your
phone if you are not home.

OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written
“authorization form.” The content of an “authorization form” is determined by federal law. Sometimes, we
may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the
process it it’s your idea for us to send your information to someone else. Typically, in this situation you will
give us a properly completed authorization form, or you can use one of ours.
If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do
not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at
any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the
office contact person named at the beginning of this Notice.

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YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information. You can:
 Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment),
payment or health care operations. We do not have to agree to do this, but if we agree, we must
honor the restrictions that you want. We must honor a restriction not to send information to a
health care plan regarding any service for which you have already made full payment. To ask for a
restriction, send a written request to the office contact person at the address, fax or Email shown at
the beginning of this Notice.

 Ask us to communicate with you in a confidential way, such as by phoning you at work rather than
at home, by mailing health information to a different address, or by using Email to your personal
Email address. We will accommodate these requests if they are reasonable, and if you pay us for any
extra cost. If you want to ask for confidential communications, send a written request to the office
contact person at the address, fax or Email shown at the beginning of this Notice.
 Ask to see or get photocopies of your health information. By law, there are a few limited situations
in which we can refuse to permit access or copying. For the most part, however, you will be able to
review or have a copy of your health information within 10 days of asking us. You may have to pay
for photocopies in advance. If we deny your request, we will send you a written explanation, and
instructions about how to get an impartial review of our denial if one is legally available. If you want
to review or get photocopies of your health information, send a written request to the office contact
person at the address, fax or Email shown at the beginning of this Notice.
 Ask us to amend your health information if you think that it is incorrect or incomplete. If we agree,
we will amend the information within 60 days from when you ask us. We will send the corrected
information to persons who we know got the wrong information, and others that you specify. If we
do not agree, you can write a statement of your position, and we will include it with your health
information along with any rebuttal statement that we may write. Once your statement of position
and/or our rebuttal is included in your health information, we will send it along whenever we make
a permitted disclosure of your health information. By law, we can have one 30-day extension of time
to consider a request for amendment if we notify you in writing of the extension. If you want to ask

us to amend your health information, send a written request, including your reasons for the
amendment, to the office contact person at the address, fax or Email shown at the beginning of this
Notice.
 Get a list of the disclosures that we have made of your health information within the past six years
(or shorter period if you want). By law, the list will not include: disclosures for purposes of
treatment, payment or health care operations; disclosures with your authorization; incidental
disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one
such list per year without charge. If you want more frequent lists, you will have to pay for them in
advance. We will usually respond to your request within 60 days of receiving it, but by law we can
have one 30-day extension of time if we notify you of the extension in writing. If you want a list,
send a written request to the office contact person at the address, fax or Email shown at the
beginning of this Notice.
 Get additional paper copies of this Notice of Privacy Practices upon request. It does not matter
whether you got one electronically or in paper form already. If you want additional paper copies,
send a written request to the office contact person at the address, fax or Email shown at the
beginning of this Notice.
You will be notified by us in a timely manner of any breach of the privacy and confidentiality of your
unsecured protected health information, which we will provide to you in accordance with law and take
all appropriate measures to address.
Fundraising. We may contact you 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.

OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We
reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new
privacy practices will apply to your health information that we already have as well as to such
information that we may generate in the future. If we change our Notice of Privacy Practices, we will
post the new notice in our office, have copies available in our office, and post it on our website.

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COMPLAINTS
If you think we have not properly respected the privacy of your health information, you are free to
complain to us of the U.S. Department of Health and Human Services, Office for Civil Rights. We will not
retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to
the office contact person at the address, fax or Email shown at the beginning of this Notice. If you
prefer, you can discuss your complaint in person or by phone.

FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit the office contact person at the
address or phone number shown at the beginning of this Notice.

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If you have any further questions please contact our office at:

1311 Jackson Ave Dental

1311 Jackson Ave

Long Island City, NY 11101

718-358-3307

info@jacksonavedental.com

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