Notice of Privacy Practices

Madison Family Dentistry
Effective April 14, 2003 / Revised July 6, 2026

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.

This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how we, our Business Associates and their subcontractors, may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present and future physical or mental health condition and related health care services. 

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your dentist, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your dental health care bills, to support the operation of the dental practice, and any other use required by law.

Treatment
We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a dental specialist or physician to whom you have been referred to ensure that the healthcare provider has the necessary information to diagnose or treat you. 

Payment
Your protected health information will be used, as needed, to obtain payment for your dental health care services. For example, obtaining approval for a procedure may require that your relevant protected health information be disclosed to the health plan to obtain approval.

Healthcare Operations
We may use or disclose, as needed, your protected health information in order to support the business activities of your dentist's practice. These activities include, but are not limited to, quality assessment, employee review, training of dental students, licensing, and conducting or arranging for other business activities.

We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you.

We may use or disclose your protected health information in the following situations without your authorization: as required by law, public health issues, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers' compensation, inmates, and other required uses and disclosures.

Uses and Disclosures That Require Your Authorization

Other permitted and required uses and disclosures will be made only with your consent, authorization, or opportunity to object unless required by law.

Without your authorization, we are expressly prohibited from using or disclosing your protected health information for marketing purposes. We may not sell your protected health information without your authorization. We may not use or disclose most psychotherapy notes contained in your protected health information. We will not use or disclose any of your protected health information that contains genetic information that will be used for underwriting purposes.

You may revoke the authorization, at any time, in writing, except to the extent that your dentist or dental practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights

Right to Inspect and Copy
Pursuant to your written request, you have the right to inspect or copy your protected health information whether in paper or electronic format. Fees may apply.

Right to Request a Restriction
You may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Right to Request Confidential Communications
You have the right to request confidential communication from us by alternative means or at an alternative location.

Right to a Paper Copy of This Notice
You have the right to obtain a paper copy of this notice from us upon request, even if you have agreed to accept this notice electronically.

Right to Request an Amendment
If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

Right to an Accounting of Disclosures
You have the right to receive an accounting of disclosures, paper or electronic, except disclosures pursuant to an authorization, for purposes of treatment, payment, or healthcare operations, or required by law.

Right to Receive Notice of a Breach
We will notify you if your unsecured protected health information has been breached.

Right to Receive Notice of Changes
We reserve the right to change the terms of this notice and we will notify you of such changes at your following appointment. We will also make available copies of our new notice if you wish to obtain one.

Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our HIPAA Compliance Officer of your complaint. We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect.

If you have any questions regarding this notice, please ask to speak with our HIPAA Compliance Officer in person or by phone at (256) 772-5757.