First Name:
Middle Initial:
Last Name:
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Office Phone: 904-737-4626

This notice describes how medical or dental information about you may be used and disclosed and how you can get access to this information.
Please review it carefully.

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 collect unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that we must do 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 help and 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 for special permission.

(We will ask for special written information 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 these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:
  • 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 healthcare 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 specialize 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 healthcare operations; - Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures.
  • Disclosures to ‘’business associates’’ who perform healthcare operations for us and who commit to respect the privacy of your health information.
Appointment Reminders
We may call or text to remind you of your scheduled appointments, or that it is time to make a routine appointment. We may also call or text to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will email you an appointment reminder, and or leave you a reminder message on your cell/home answering machine or with someone who answers your phone if you were 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 authorization process if the use or disclosure is our idea.

Sometimes, you may initiate the process if it is 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 the 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 anytime unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person name at the beginning of this notice.

Your Rights Regarding Your Health Information
The law gives you money right regarding your health information. You can
  • Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or healthcare operations. We do not have to agree to 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 for 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 and 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 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-dayextension 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 for healthcare 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 list, 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 to 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.
Be notified by us in a timely matter 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.

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 his 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.

If you think we have not properly respected the privacy of your health information, you are free to complain to us of the US 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 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 one of the offices listed at the beginning of this notice.

I have read the above Joy Orthodontics Notice of Privacy Practice. By my signature I acknowledge that I understand and agree to abide by its terms.