HIPAA Notice of Privacy Practices

Our Pledge Regarding Health Information

Willis & Associates Family Dentistry - Churchville is committed to protecting health information about you. We are required by law to maintain the privacy of protected health information (PHI), to provide you with this Notice of our legal duties and privacy practices with respect to your PHI, and to follow the terms of the Notice currently in effect.

How We May Use and Disclose Health Information

Federal law permits us to use and disclose your PHI without your written authorization for treatment, payment, and health care operations. Examples include:

• Treatment. We may use your information to coordinate dental care and consult with other providers involved in your care.
• Payment. We may use and disclose your information to bill and collect payment for the services we provide, including communicating with your insurance plan.
• Health care operations. We may use your information for activities necessary to run our practice, including quality assessment, training, accreditation, and business management.
• Appointment reminders and follow-up. We may contact you to remind you of an appointment or to discuss treatment options.
• As required by law. We will disclose information when required by federal, state, or local law, including reporting to public health authorities.

Your Rights Regarding Your Health Information

Under HIPAA (45 CFR §164.520), you have the following rights:

• The right to inspect and request a copy of your dental record.
• The right to request an amendment to your record if you believe it is incorrect or incomplete.
• The right to request an accounting of certain disclosures we have made of your PHI.
• The right to request restrictions on how we use or disclose your PHI for treatment, payment, or health care operations.
• The right to request confidential communications by an alternative means (for example, contact at home rather than at work).
• The right to a paper copy of this Notice, even if you agreed to receive it electronically.
• The right to be notified following a breach of unsecured PHI.

Filing a Complaint

If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.

• Our office:Privacy Officer, Willis & Associates Family Dentistry - Churchville, 21 Scenic Hwy, Churchville, VA 24421. Phone 540-337-6004. Email churchville@willisdentistry.com.
• HHS Office for Civil Rights: File a complaint online or call 1-800-368-1019.

Changes to This Notice

We reserve the right to change this Notice and to make the revised Notice effective for all PHI we maintain. We will post a copy of the current Notice in our office and on this website.