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 applies to Austin Dental Plus and all doctors, hygienists, staff, and personnel who provide care to you at our Forest Hills, NY office. We are required by law to maintain the privacy of your protected health information ("PHI"), to provide you with this Notice describing our legal duties and privacy practices, and to abide by the terms of the Notice currently in effect.
How We May Use and Disclose Your Health Information
Treatment. We may use and disclose your PHI to provide, coordinate, or manage your dental care. For example, we may share information about your treatment with a specialist we refer you to, or with your physician if relevant to your care.
Payment. We may use and disclose your PHI to obtain payment for services we provide. For example, we may send your insurance carrier information about a procedure so they can process a claim.
Health Care Operations. We may use and disclose your PHI for our own operations, such as quality assessment, staff training, and practice management. For example, we may review your chart as part of an internal quality review.
Appointment Reminders and Treatment Alternatives. We may contact you (by phone, text, mail, or email) to remind you of an appointment, or to tell you about treatment alternatives or health-related benefits and services that may interest you.
Individuals Involved in Your Care. Unless you object, we may share relevant information with a family member, friend, or other person you identify as involved in your care or payment for your care.
Uses and Disclosures That Do Not Require Your Authorization
In limited circumstances, federal or state law permits or requires us to use or disclose your PHI without your authorization, including: as required by law; for public health activities (e.g., reporting communicable disease); to report suspected abuse, neglect, or domestic violence; for health oversight activities (e.g., audits, licensure); in connection with judicial or administrative proceedings (e.g., a court order); for law enforcement purposes; to coroners, medical examiners, or funeral directors; for organ or tissue donation; for research, subject to privacy safeguards; to avert a serious threat to health or safety; for specialized government functions (e.g., military, national security); for workers' compensation; and for disaster relief efforts.
Uses and Disclosures That Require Your Written Authorization
Other than the uses and disclosures described above, we will not use or disclose your PHI without your written authorization. This includes most uses and disclosures for marketing purposes, and any sale of your PHI. If you provide us with authorization, you may revoke it in writing at any time, except to the extent we have already acted in reliance on it.
Your Rights Regarding Your Health Information
Right to Request Restrictions. You have the right to request a restriction on how we use or disclose your PHI for treatment, payment, or health care operations. We are not required to agree, except: if you pay for a service in full, out of pocket, you have the right to request that we not disclose information about that service to your health plan, and we must honor that request.
Right to Confidential Communications. You may request that we communicate with you about your health information in a specific way or at a specific location (for example, only by mail, or only at a work number).
Right to Inspect and Copy. You have the right to inspect and obtain a copy of your dental records, with limited exceptions. We may charge a reasonable, cost-based fee for copies.
Right to Amend. You have the right to request that we amend your health information if you believe it is incorrect or incomplete. We may deny your request in certain circumstances, and will explain the reason in writing.
Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we have made of your PHI, other than for treatment, payment, health care operations, and certain other excepted disclosures.
Right to a Paper Copy. You have the right to receive a paper copy of this Notice at any time, even if you agreed to receive it electronically.
Right to Choose Someone to Act for You. If you have given someone medical power of attorney, or if someone is your legal guardian, that person may exercise your rights and make choices about your health information.
Right to Be Notified of a Breach. You have the right to be notified if a breach occurs that may have compromised the privacy or security of your PHI.
Right to Opt Out of Fundraising Communications. If we ever contact you to raise funds for our practice, you have the right to tell us not to contact you again for that purpose.
Our Responsibilities
We are required by law to maintain the privacy and security of your PHI; to notify you promptly if a breach occurs that may have compromised your information; to follow the terms of this Notice currently in effect; and not to use or share your information other than as described here, except with your written authorization. If you provide authorization, you may revoke it at any time, in writing.
Changes to This Notice
We reserve the right to change this Notice and to make the revised Notice effective for PHI we already have as well as any information we receive in the future. We will post the current Notice on our website and in our office, with its effective date.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer at the contact information below, or with the U.S. Department of Health & Human Services, Office for Civil Rights, by visiting www.hhs.gov/ocr/complaints or calling 1-800-368-1019. We will not retaliate against you for filing a complaint.
Contact / Privacy Officer
Austin Dental Plus — Attn: Privacy Officer
11074 Queens Blvd, Forest Hills, NY 11375
Phone: (718) 544-5055
Effective date: July 11, 2026. This Notice is provided in accordance with 45 CFR §164.520 and applies to protected health information created or received by Austin Dental Plus.