Van Buren Dental Notice of Privacy Practices

(includes Omnibus changes as of March 2013)

Effective Date: 9/21/2025

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.

If you have any questions about this Notice of Privacy Practices (“Notice”), please contact:
Privacy Officer: OFFICE MANAGER
Phone Number: (937) 253-9115

Who Will Follow This Notice?

This Notice describes VAN BUREN DENTAL (“Provider”) Privacy Practices and that of any workforce member authorized to create medical information (Protected Health Information, PHI) which may be used for Treatment, Payment, and Healthcare Operations. Workforce members include all departments, staff, volunteers, and entities providing services under the Provider's direction and control.

Our Pledge Regarding Medical Information

We are committed to protecting your medical information. We create records of the care and services you receive and need these records for quality care and legal compliance. This Notice applies to all records generated or maintained by the Provider, whether by Provider personnel or your personal doctor.

We are required by law to keep your information private.
We must give you this Notice about our legal duties and privacy practices.
We must follow the terms of the Notice currently in effect.

How We May Use and Disclose Medical Information About You

We may use and disclose medical information for the following purposes (examples included):

Treatment: To provide you with medical care, and coordinate with others involved in your care.
Payment: To bill for your treatment and collect payment.
Healthcare Operations: To run our practice and ensure quality care.
Appointment Reminders: To remind you of appointments.
Treatment Alternatives: To inform you about treatment options.
Health-Related Benefits and Services: To tell you about health-related benefits or services.
Fundraising Activities: To contact you for fundraising, with an option to opt-out in writing.
Authorizations Required: We will not use your PHI for purposes not allowed by law without your written authorization (including marketing or sales).
Emergencies: If you need emergency treatment and we can't get your consent, we will try to obtain it as soon as possible.
Psychotherapy Notes: These have stricter protections and require written authorization to disclose (with limited exceptions).
Communication Barriers: If substantial barriers exist, we may use your info if we believe you would consent.
Provider Directory: Basic info may be listed in our directory unless you object in writing.
Individuals Involved in Your Care: We may share info with those involved in your care or payment, unless you object.
Research: We may use or disclose info for research, subject to approval and privacy protections.
As Required by Law: We will disclose info as required by federal, state, or local law.
To Avert a Serious Threat: To prevent a serious threat to health or safety.
Email Use: Email is only used per our policies and your permission; secured, encrypted email is encouraged.

Special Situations

Organ and Tissue Donation
Military and Veterans
Workers' Compensation
Public Health Risks (disease prevention, reporting abuse, recalls, etc.)
Health Oversight Activities
Lawsuits and Disputes
Law Enforcement
Coroners, Medical Examiners, and Funeral Directors
National Security and Intelligence Activities
Protective Services for the President and Others
Inmates (as needed for care or safety)

Your Rights Regarding Medical Information About You

Right to Access, Inspect, and Copy: You may request a copy of your medical/billing records (fees may apply).
Right to Amend: You may ask us to amend incorrect or incomplete information (in writing, with a reason).
Right to an Accounting of Disclosures: Request a list of disclosures we made about you (some limits apply).
Right to Request Restrictions: Request limits on what we use/disclose, though we are not required to agree except in certain payment cases.
Right to Receive Notice of a Breach: We will notify you if your unsecured health information is breached.
Right to Request Confidential Communications: Request that we contact you in specific ways/locations.
Right to a Paper Copy of This Notice: You can always request a paper copy of this Notice.

To exercise these rights, contact the individual listed at the top of this Notice.

Changes to This Notice

We reserve the right to change this Notice and make changes effective for all medical information we have about you. We will post the current Notice and provide it when you register or are admitted for treatment.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services: HIPAA Complaint Page

To file a complaint with us, contact the Privacy Officer listed above. All complaints must be in writing. You will not be penalized for filing a complaint.

Other Uses of Medical Information

Other uses and disclosures not covered by this Notice or laws that apply to us will only be made with your written permission. You may revoke permission at any time in writing, but disclosures already made cannot be taken back.

Organized Healthcare Arrangement

The Provider and independent contractor members of its Medical Staff (including your physician) and other healthcare providers affiliated with the Provider may share your health information for purposes of treatment, payment, or healthcare operations.