A. Hallie Lillmars, D.D.S.
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.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect (2/16/2025) and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
Your Authorization: Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.
Plan Sponsors: If your dental insurance coverage is through an employer sponsored group dental, we may share summary health information with the plan sponsor.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
Public Health and benefit Activities: We may use and disclose your medical information, without your permission, when required by law and when authorized by law for the following kinds of public health and public benefit activities;
• For public health, including to report disease and vital statistics, child abuse, adult abuse, neglect or domestic violence;
• To avert a serious imminent threat to health or safety;
• For health care oversight, such as activities of state insurance commissioners, licensing and peer review authorities and fraud prevention agencies;
• For research;
• In response to court and administrative orders and other lawful process;
• To law enforcement officials with regard to crime victims and criminal activities;
• To coroners, medical examiners, funeral directors and organ procurement organizations;
• To the military, to federal officials for lawful intelligence, counterintelligence, and national security activities, and also correctional institutions and law enforcement regarding persons in lawful custody; and
• As authorized by state worker’s compensation laws.
Special protections for SUD records; Substance Use Disorder (SUD) Treatment records have enhanced protections that is protected under 42 CFR part 2. They cannot be used in legal proceedings without your consent or court order.
Redisclosure: Certain disclosures of your health information may no longer be protected by HIPAA after they are shared with authorized recipients. However, records protected under 42 CFR Part 2 remain subject to restrictions on redisclosures unless permitted by law.
Uses and Disclosures that Require Your Written Authorization; We will not use or disclose your PHI for purpose such as Marketing, sale of PHI or any other use not described in this notice, without your written consent. You may revoke an authorization at any time in writing.
Business Associates: We may disclose your medical information to our business associate that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. Our business associates are required, under contract with is, to protect the privacy of your information and are not allowed to use or disclose any information other than as specific in our contract.
Data Breach Notification Purposes: We may use your contact information to provide legally required notices to unauthorized acquisition, access or disclosure of your health information.
Cybersecurity and Information Security Practices; We are committed to protecting the privacy and security of your health information. In addition to the privacy protections described in this Notice, we have adopted and maintain administrative, technical, and physical safeguards designed to protect your protected health information (PHI) against unauthorized access, use, disclosure, or destruction. These safeguards include; risk assessment and management, monitoring and incident dictation. We continually review and update our security practices to align with applicable law and emerging regulatory requirements, including proposed cybersecurity standards.
Additional Restrictions on use and disclosure: Certain federal and state laws require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly Confidential information” may include confidential information under Federal laws governing reproductive rights, alcohol abuse and drug abuse information and genetics information as well as state laws that often protect the following; HIV/AIDS, Mental Health, Genetic test (in accordance with GINA 2009), Alcohol and drug abuse, sexually transmitted disease and reproductive health information, and child/adult abuse or neglect, including sexual assault.
Patient Rights: You have the right to request access to or a copy of your health records, request corrections to your health information, request confidential communications, request restrictions on certain uses or disclosures, receive an accounting of disclosures, receive a paper copy of this Notice, even if you agreed to receive it electronically. You have the right to request amendment to be made to your health records by submitting the request in writing to our privacy officer. Your request does not guarantee the amendment, but for guarantee that it will be reviewed and considered. If you believe your rights are being denied or your health information is not being protected, you can: A) file a complaint with your provider or health insurer B) File a compliant with the U.S Government
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services, 200 Independence Ave, SW, Room 509F, Washington, DC, 20201. You may contact the Office for Civil Rights’ hotline at 1-800-368-1019. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Contact Officer: Katie Fink
Telephone: 314-962-0880 Fax: 314-961-6777
Address: 8720 Big Bend Blvd., Suite A, Webster Groves, MO 63119
© 2002 American Dental Association
All Rights Reserved
Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.
This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).