Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Park Dental respects your privacy. We maintain records containing your personal health information that are protected by law. This Notice of Privacy Practices explains how we may use or disclose your protected health information, your rights and our legal duties regarding your protected health information. In this Notice, your protected health information is called your “Health Information.”

Our Duties Regarding Your Health Information

Park Dental is required by law to maintain the privacy of your Health Information and provide you with this Notice of our legal duties and privacy practices with respect to your Health Information. We reserve the right to change our privacy practices and this Notice and make the revised Notice effective for all your Health Information we maintain. We will post a copy of the current Notice in a clear and prominent location in our facility and post it on our website if we maintain a website. We must follow the terms of the Notice that is in effect. You may request a copy of the Notice currently in effect at any time. If you have questions or would like further information about this Notice, please contact our Privacy Official, whose contact information is at the end of this Notice.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

Treatment, Payment and Health Care Operations

We are permitted to use and disclose your Health Information for purposes of treatment, payment and health care operations.

• Treatment: We may use or disclose your Health Information to provide you with health care treatment or services. For example, we may use your Health Information to diagnose and treat you, or we may disclose your Health Information to a health care provider you may be referred to so the provider has the information needed to diagnose or treat you.
• Payment: We may use or disclose your Health Information to obtain payment or be reimbursed for the health care treatment and services we provide. For example, we may give your Health Information to your health plan so it can reimburse you or pay us. We may also provide your Health Information to your health plan to obtain prior approval for treatment or to determine whether your plan will cover the treatment.
• Health Care Operations: We may use or disclose your Health Information in connection with our health care operations, which are ways we provide health care and manage our organization. For example, we may use or disclose your Health Information to evaluate our performance in providing health care to you and identify ways we may improve our service.
• Activities Permitted or Required by Law: There are situations besides treatment, payment or health care operations required or permitted by law where we may use or disclose some of your Health Information without first obtaining your written authorization in the following situations.
• Public Health: We may disclose your Health Information to a public health authority responsible for preventing or controlling disease, maintaining vital statistics or other public health functions and to a public health authority or other appropriate government authority authorized by law to receive reports of child or adult abuse, neglect or domestic violence. We may also give your Health Information to the Food and Drug Administration in connection with FDA-regulated products.
• Health Oversight Activities: We may disclose your Health Information to a health oversight agency authorized by law to monitor the health care system. Authorized health oversight activities include audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; civil, administrative or other activities necessary for appropriate oversight of the health care system.
• Judicial and Administrative Proceedings: We may disclose your Health Information in response to a subpoena or order of a court or administrative tribunal.
• Law Enforcement Purposes: We may disclose your Health Information in response to a law enforcement official’s request for information to identify or locate a victim, a suspect, a fugitive, a material witness or a missing person (including individuals who have died) or for reporting a crime that has occurred on our premises or that may have caused a need for emergency services.
• Required by Law: We may use or disclose your Health Information when required by state, federal or other laws to correctional institutions, the Food and Drug Administration and authorized federal officials for the conduct of lawful national security activities and the provision of protective services to the President or other persons as required by federal law.
• Coroners, Medical Examiners and Funeral Directors: We may disclose your Health Information to coroners or medical examiners to identify a deceased person or determine cause of death and to funeral directors to carry out their duties.
• Research: We may use or disclose your Health Information for research purposes under strict legal protection only if the use or disclosure has been reviewed and approved by a special Privacy Board or Institutional Review Board or if you authorize the use or disclosure.
• Disaster Relief Incidents: We may use or disclose your Health Information to a public or private entity authorized to assist in disaster relief efforts, such as the American Red Cross. If you tell us you object, we will not make this use or disclosure unless we must do so to respond to an emergency situation.
• Persons Involved in Your Care: We may use or disclose your Health Information to persons involved in your health care or payment for health care, including family members, your personal representative or another person identified by you, unless you object to our use and disclosure to such persons.
• Workers Compensation: We may use or disclose your Health Information to comply with worker’s compensation laws.
• Avert a Serious Threat to Health or Safety: We may use or disclose your Health Information if we believe it is necessary to prevent or lessen a serious threat to your health or the health or safety of a person or the public.
• Military: If you are a member of the armed forces, we may release medical information about you to military authorities as authorized or required by law. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
• Business Associates: We may use persons or organizations called Business Associates to perform work or services such as legal, accounting or financial services requiring use or disclosure of your Health Information, but only if a Business Associate agrees by written contract to safeguard your Health Information as required by law.
• Fundraising: We may use limited Health Information such as your name, address and treatment dates to contact you for fundraising purposes to support our health care purposes and mission. You have the right to elect not to receive fundraising communications. A fundraising communication will include simple instructions to stop receiving fundraising communications permanently.

Use and Disclosure of Your Health Information Requiring Written Authorization

Your written authorization is required for the following uses and disclosures of your Health Information:

• Marketing: We will not use or disclose your Health Information for marketing purposes without your written authorization. Marketing is defined as a communication about a product or service related to your health care for which we receive payment from a third party.
• Sale of your Health Information: We will not sell your Health Information without your written authorization.
• Psychotherapy Notes: If we maintain psychotherapy notes about you we will not disclose psychotherapy notes without your written authorization except in limited instances that are permitted or required by law.
• Reproductive Health Information: We are prohibited by law from using or disclosing Health Information related to your reproductive system and its functions and processes to identify, investigate or impose criminal or civil liability on any person for the mere act of seeking, obtaining, providing, or facilitating reproductive health care. For example, we may not disclose the information to a police officer investigating a reproductive health procedure that violates state law. However, we can disclose reproductive health information for purposes permitted and not prohibited by law like providing you with health care treatment. Before we disclose information potentially related to reproductive health for health oversight activities, judicial and administrative proceedings, law enforcement purposes or to coroners and medical examiners, we must receive a valid legal document called an Attestation stating the information will not be used for a prohibited purpose. For example, a local health department must confirm it is not requesting the information to identify a person seeking, obtaining, providing, or facilitating lawful reproductive health care. Health information we disclose in compliance with law may be redisclosed by the recipient and no longer protected by Federal law.

All Other Uses and Disclosures of Your Health Information Require Written Authorization

Your written authorization is required for other uses and disclosures of your Health Information not described in this Notice. You may revoke an authorization to use or disclose your Health Information in writing anytime. Your revocation will not affect uses or disclosures made in reliance on your authorization before the revocation. If the Authorization was obtained as a condition of obtaining insurance coverage, other laws may provide the insurer with the right to contest a claim under the policy or the policy itself.

Your Rights Regarding Your Health Information

This section explains your rights and how you can make use of your rights regarding your Health Information.

• Your Right to Our Notice of Privacy Practices: You have the right to obtain a paper copy of our current Notice of Privacy Practices. You have the right to receive an electronic copy of this Notice from our web site if we maintain one or, if you agree in writing, by email. You have the right to obtain a paper copy of this Notice at any time, even if you have agreed to receive it electronically. You may ask our Privacy Official, whose contact information is at the end of this Notice, to provide you with a copy of our current Notice at any time.
• Your Right to Request Restrictions: You have the right to request a restriction of your Health Information we use or disclose for treatment, payment or health care operations and Health Information disclosed to someone who is involved in your care or payment for your care, like a family member or friend. Your request must be in writing and given to our Privacy Official, whose contact information is at the end of this Notice. We will provide you with the form to make your written request. We are not required to agree to your request in all circumstances. We must agree to your request to restrict disclosure of your Health Information to your health plan if the disclosure is not required by law and the health information you want restricted pertains solely to a health care item or service for which you (or someone other than your health plan, on your behalf) have paid us for in full. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment and we will request that health care provider not to further use or disclose your Health Information. We may terminate our restriction if you ask us to terminate it. We may also terminate a restriction if we inform you we are terminating it. Terminating a restriction will only affect Health Information created or received after we inform you of the termination.
• Confidential Communications: You have the right to request that we communicate with you about your Health Information by alternative means or at an alternative location. For example, you can ask that we contact you by telephone at work or by mail in a sealed envelope (not a postcard). We will accommodate all reasonable requests. Your request for Confidential Communications must be in writing and given to our Privacy Official, whose contact information is at the end of this Notice. We will provide you with the form to make your written request.
• Inspect and Get a Copy of your Health Information: You have the right to inspect and get a copy of your Health Information we maintain that may be used to make decisions about your treatment and care, including billing records, for as long as we maintain the information. You may also request an electronic copy of your Health information if we maintain it electronically. Your request must be in writing and given to our Privacy Official, whose contact information is at the end of this Notice.
  We will provide you with the form to make your written request and provide access to your Health Information except in some limited circumstances. If we deny any part of your request, we will explain in writing why we made the denial, if and how you may request a review of our denial and how you may make a complaint to us and the Secretary of the US Department of Health and Human Services about our denial. We may charge a reasonable, cost-based fee for making copies of your Health Information, but we will not charge a fee for inspecting your Health Information at a convenient time and place.
• Request Amendment of your Health Information: If you believe your Health Information we maintain is incorrect or incomplete you have the right to request we amend that Health Information. Your request must be in writing and given to our Privacy Official, whose contact information is at the end of this Notice. We will provide you with the form to make your written request. We will inform you of our action on your request, including what we will do if we accept your request for amendment in whole or in part. If we deny all or part of your request for amendment, we will provide you with the reasons for the denial and inform you of your additional rights regarding our denial, including your right to complain to us and the Secretary of the US Department of Health and Human Services.
• Accounting of Disclosures: You have the right to receive a list (accounting) of certain disclosures of your Health Information we have made. Your request for an accounting of these disclosures must be in writing and given to our Privacy Official, whose contact information is at the end of this Notice. We will provide you with the form to make your written request, and we will provide you with the accounting in writing. You may request an accounting of disclosures for up to six (6) years before the date you make the request. We will provide the accounting free of charge, but if you request an accounting more than once in a twelve (12) month period, we may charge you a reasonable, cost-based fee and let you know the cost so you can modify your request to reduce the fee or withdraw it.
• Complain that Your Privacy Rights Have Been Violated: If you believe your privacy rights have been violated, you have the right to file a complaint with us and with the Secretary of the US Department of Health and Human Services. We will not retaliate against you for filing a complaint that your privacy rights have been violated. You may file a complaint with us by contacting the office of our Privacy Official, whose contact information is at the end of this Notice. Information about making a complaint to the Secretary is at the end of this Notice.

Contact Information

For more information about the matters covered by this Notice, your health information rights, or to complain that your privacy rights have been violated, please contact our Privacy Official, whose contact information is at the end of this Notice. If you wish, we will provide you with a form to make your complaint in writing. We will not retaliate against you for filing a complaint that your privacy rights have been violated.

• Park Dental Privacy Official
  2200 County Road C Suite 2210
  Roseville, MN 55113
  Phone: 651-746-2815

US Department of Health and Human Services: You may make a health information privacy or security complaint to the Secretary of the US Department of Health and Human Services (HHS). We will not retaliate against you for making the complaint. A complaint to HHS must be _led within 180 days of when you first knew of the reasons you believe your health information privacy rights were violated, although the 180-day period can be extended if you can show “good cause.” You may file a Health Information Privacy Complaint with the Secretary online through the HHS Complaint Portal or obtain a Health Information Privacy Complaint Form Package to fill out, print and submit by mail, fax or email.

If you have any questions about filing a complaint, contact the Department of Health and Human Services, Office for Civil Rights at 1-800-368-1019 (voice), TDD: 1-800-537-7697. You may also send an email message to [email protected] or fax to (202) 619-3818

This notice is effective as of January 13, 2025.