Your Information. Your Rights. Our Responsibilities.
This notice explains how Tarboro Family Dentistry may use and disclose your protected health information (PHI), the rights you have, and our legal responsibilities. “Health information” includes dental records and other individually identifiable health information that we create, receive, or maintain.
Your Rights
Get an electronic or paper copy of your records. You may inspect or request a copy of your dental record and other information we maintain about you. We generally will respond within 30 days, subject to any extension allowed by law. We may charge only a reasonable, cost-based fee permitted by law. Some limited exceptions to access apply.
Ask us to correct your records. If you believe information is incorrect or incomplete, you may request an amendment. We may deny a request in certain circumstances but will explain the reason in writing, generally within 60 days, subject to permitted extensions.
Request confidential communications. You may ask us to contact you at a different telephone number, address, or through another reasonable method. We will accommodate reasonable requests.
Ask us to limit certain uses or disclosures. You may ask us not to use or disclose certain information for treatment, payment, or operations. We generally are not required to agree. If you pay in full out of pocket for a service, you may require us not to disclose information about that service to your health plan for payment or health care operations, unless disclosure is required by law.
Request an accounting of disclosures. You may request an accounting of certain disclosures made during the six years before your request. Some disclosures, including most for treatment, payment, or health care operations, are excluded. One accounting in a 12-month period is free; additional accountings may involve a reasonable, cost-based fee.
Receive a copy of this notice. You may request a paper copy at any time, even if you previously agreed to receive it electronically.
Choose a representative. A person with legal authority to act for you, such as a guardian or an authorized health care representative, may exercise your rights, subject to verification of authority and applicable law.
File a complaint. If you believe your privacy rights have been violated, contact our Privacy Officer using the details below or file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights: https://www.hhs.gov/hipaa/filing-a-complaint/index.html (opens in a new tab); 1-877-696-6775; 200 Independence Avenue SW, Washington, DC 20201. We will not retaliate against you for filing a complaint.
Your Choices
Family, friends, and others involved in your care. You may tell us your preferences about sharing relevant information with family, friends, or others involved in your care or payment for care. If you cannot tell us your preference, we may share information when we believe it is in your best interest and permitted by law.
Disaster relief. We may share information with authorized disaster-relief organizations as permitted by law. You may tell us your preference when practicable.
Marketing, sale of PHI, and other uses requiring authorization. We generally must obtain your written authorization before using or disclosing PHI for marketing where authorization is required, selling PHI, or other purposes requiring authorization under HIPAA. Most uses and disclosures of psychotherapy notes also require authorization. You may revoke an authorization in writing, except to the extent we already relied on it.
Fundraising. We do not currently use patient health information for fundraising. If our practices change, we will comply with applicable notice and opt-out requirements.
How We Typically Use and Disclose Your Information
Treatment. We may use your information and share it with other health professionals to provide or coordinate treatment. Example: We send dental X-rays and treatment history to an oral surgeon to whom we refer you.
Payment. We may use or disclose information to bill and collect payment for services. Example: We send treatment and procedure information to your dental insurer to process a claim.
Health care operations. We may use or disclose information to operate the Practice, evaluate quality, train staff, and improve care. Example: We review records internally to assess quality and scheduling practices.
Other Permitted or Required Uses and Disclosures
As allowed or required by law and subject to applicable conditions, we may use or disclose PHI for public health reporting, disease prevention, product recalls, reporting suspected abuse or neglect, responding to serious threats to health or safety, health oversight, research, organ or tissue donation, medical examiners or funeral directors, workers’ compensation, certain law-enforcement requests, judicial or administrative proceedings, military or national-security functions, and other legally authorized purposes. We may disclose information to the Secretary of Health and Human Services to demonstrate compliance with HIPAA. Additional federal or North Carolina confidentiality laws may impose stricter limits on particular information, and we will follow those laws.
Our Responsibilities
We must maintain the privacy and security of your PHI, provide this notice, and follow the terms of the notice currently in effect. We must notify affected individuals following a breach of unsecured PHI when required by law. We will not use or disclose PHI in ways not described here unless permitted or required by law or you authorize us in writing. You may revoke an authorization in writing, subject to actions already taken in reliance on it.
Changes to This Notice
We may revise this notice as permitted by law and apply revised terms to all PHI we maintain. A revised notice will be available on request, prominently displayed at the Practice, and posted on our website if we maintain one providing information about our services. You may request a copy at any time.
Questions, Requests, or Complaints
Privacy Officer: Dr. Gray Bailey, D.M.D.
Administrative contact: Office Manager, Tarboro Family Dentistry
801 Western Boulevard, Tarboro, NC 27886
Telephone: (252) 823-5739 | Fax: (252) 823-0353
Email: tarborofamilydentistry@gmail.com
Website: www.tarborofamilydentistry.com