Notice of Privacy Practices for Protected Health Information

Amendment Date: 09.01.26

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.

How We May Use and Disclose Your Health Information

We use and disclose your protected health information (“PHI”) to provide, coordinate, and bill for your dental treatment and for the other purposes described below. The following categories describe the ways we typically use and disclose PHI without asking for your written authorization.

• Treatment: We may use and disclose your PHI to provide, coordinate, or manage your dental care and any related services. For example, we may share information about your treatment with a specialist, laboratory, or other provider involved in your care, or with a dentist covering our practice after hours.
• Payment: We may use and disclose your PHI to obtain payment for the services we provide. For example, we may send billing information to your dental or health insurance plan, or to a collection agency, so that we are paid for services rendered.
• Health Care Operations: We may use and disclose your PHI to run our practice and make sure our patients receive quality care. Examples include quality assessment and improvement activities, staff training, licensing, credentialing, business planning, and internal audits.

Your Health Information Rights

You have the following rights with respect to the PHI we maintain about you. To exercise any of these rights, please submit a written request to our Compliance Department atCompliance@mysagedental.com.

• Right to Inspect and Copy: You have the right to inspect and obtain a copy of the PHI we maintain about you, such as your dental and billing records, with limited exceptions. We may charge a reasonable, cost-based fee for copies.
• Right to Request Amendment: You have the right to request that we amend PHI you believe is incorrect or incomplete. We may deny your request in certain circumstances, and we will explain our reasons in writing if we do.
• Right to an Accounting of Disclosures: You have the right to receive a list of certain disclosures we have made of your PHI, other than disclosures for treatment, payment, health care operations, and certain other excepted disclosures.
• Right to Request Restrictions: You have the right to request a restriction on the PHI we use or disclose about you for treatment, payment, or health care operations, or to family members and others involved in your care. We are not required to agree, except that we must agree to a request to restrict disclosure to a health plan if the disclosure is for payment or health care operations and pertains to a service you (or someone on your behalf) paid for out-of-pocket in full.
• Right to Request Confidential Communications: You have the right to request that we communicate with you about your health matters in a certain way or at a certain location — for example, by contacting you only at work or by mail. We will accommodate all reasonable requests.
• Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice at any time, even if you agreed to receive it electronically.
• Right to Choose Someone to Act on Your Behalf: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your PHI.
• Right to Be Notified of a Breach: You have the right to be notified if a breach occurs that may have compromised the privacy or security of your PHI.

Uses and Disclosures that Require Your Written Authorization

Other than as described in this Notice, we will not use or disclose your PHI without your written authorization. The following uses and disclosures require your specific written authorization:

• Marketing: Most uses and disclosures of your PHI for marketing purposes require your written authorization.
• Sale of PHI: Any disclosure of your PHI that constitutes a sale of PHI, as defined by law, requires your written authorization.
• Psychotherapy Notes: Most uses and disclosures of psychotherapy notes, where applicable, require your written authorization.
• Other Uses: Any other uses and disclosures not described in this Notice will be made only with your written authorization.

You may revoke an authorization you have given us at any time, in writing, except to the extent we have already acted in reliance on it.

Our Responsibilities

The practice is required to:

• Maintain the privacy of your health information as required by law;
• Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you;
• Abide by the terms of this Notice;
• Notify you if we cannot accommodate a requested restriction or request;
• Accommodate your reasonable requests regarding methods to communicate health information with you;
• Notify you if you are affected by a breach of unsecured PHI; and
• Provide you with adequate notice of your rights and our legal duties if we create or maintain records protected by 42 C.F.R. Part 2 which protects the confidentiality of patient records for individuals receiving substance use disorder (SUD) treatment and applies only to records created by federally assisted programs providing SUD diagnosis, treatment, or referral for treatment.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our Notice or by visiting our office and picking up a copy.

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Compliance@mysagedental.com or 561-999-9650.

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Angie Ferguson, Vice President, Compliance. You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services.

The U.S. Department of Health & Human Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington, D.C. 20201
Toll Free Call Center: 1-877-696-6775

• We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the practice.
• We cannot, and will not, retaliate against you for filing a complaint with the Secretary.

Other Disclosures and Uses

Notification: Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Communication with Family: Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency.

Food and Drug Administration (FDA): We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Workers Compensation: If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health: As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Abuse & Neglect: We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Correctional Institutions: If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health and safety of other individuals.

Law Enforcement: We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.

Health Oversight: Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings: We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.

Other Uses: Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.

Website: If we maintain a website that provides information about our entity, this Notice will be on the website.