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.

1. OUR PLEDGE REGARDING HEALTH INFORMATION

At Henderson Family Dental Care INC, under the direction of Dr. Gilsa Henderson, we understand that health information about you and your health is personal. We are committed to protecting health information about you. We create a record of the care and services you receive at our facility to provide you with quality care and to comply with certain legal requirements.

2. HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION (PHI)

We may use and disclose your PHI for the following purposes without your specific authorization:

- For Treatment: We may use your PHI to provide you with dental treatment or services. We may disclose PHI to dental specialists, physicians, or other healthcare personnel who are involved in your care.

- For Payment: We may use and disclose your PHI so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company, or a third party.

- For Healthcare Operations: We may use and disclose PHI for clinic operations. These uses and disclosures are necessary to run the practice and make sure that all of our patients receive quality care.

- Appointment Reminders: We may use and disclose PHI to contact you as a reminder that you have an appointment for treatment or dental care (via phone, email, or SMS).

- As Required By Law: We will disclose PHI when required to do so by international, federal, state, or local law.

3. SPECIAL SITUATIONS

We may release PHI about you for public health activities, lawsuits and disputes, law enforcement, or to avert a serious threat to health or safety, as permitted by HIPAA regulations.

4. YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding the PHI we maintain about you:

- Right to Inspect and Copy: You have the right to inspect and receive a copy of your dental and billing records.

- Right to Amend: If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information.

- Right to an Accounting of Disclosures: You have the right to request a list of certain disclosures we made of your PHI for purposes other than treatment, payment, or healthcare operations.

- Right to Request Restrictions: You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment, or healthcare operations. We are not required to agree to your request unless it is for a service you paid for in full out-of-pocket.

- Right to Confidential Communications: You have the right to request that we communicate with you about dental matters in a certain way or at a certain location.

5. CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for PHI we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our office and on our website: hendersondentalclinic.com.

6. COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. There will be no retaliation for filing a complaint.

7. CONTACT INFORMATION

If you have any questions about this notice or wish to exercise any of your rights, please contact our Privacy Officer:

Privacy Officer: Dr. Gilsa Henderson

Entity: Henderson Family Dental Care INC.

Address: 4963 W 6th Ave, Hialeah, FL 33012

Phone: (305) 558-1171

Email: [email protected]