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HIPAA Privacy Compliance


  • Notice of Privacy Practice

  • This notice describes how medical / dental information about you may be used/disclosed and how you can get access to this information. Please review it carefully. Our commitment here at TMJ Dental Health Center is to serve our clients with professionalism, assuring at all times the protection of privacy and security of all Protected Health Information. When you receive care from TMJ Dental Health Center we may use your health information for treating you, billing for services, and conducting our normal business known as dental care operations. Examples of how we use your information include:

    Treatment: We may use and disclose your dental information to plan, provide and coordinate your dental care services. For example, we may make your dental information available to other providers for review of treatment options or to enable them to schedule visits appropriate for review of treatment options or to enable them to schedule visits appropriate for your treatment.

    Payment: We may use and disclose your dental information and records to obtain payment for dental services we have provided for you. For example, we may provide copies of notes and x-rays made during your visit to the appropriate insurance company to enable them to make payment for services you received.

    Health Care Operation: We may use or disclose your protected health information for our health care operations. For example, we may use or disclose your personal health information to perform risk assessments and other administrative tasks to monitor the quality of care we provide. For uses and disclosures of your personal dental information not involving treatment, payment of health care operations, we will receive your written authorization prior to using or disclosing any personal health information (unless required or permitted by law). You have the right to revoke any authorization previously granted.

    We may use and disclose your personal health information without obtaining your consent or authorization in the following situations:

    - To recommend treatment alternatives

    - To tell you about dental services and products that may benefit you.

    - To remind you of an appointment

    - Share information with third parties who help us with treatment, payment, and other health operations. Our business associates must follow our privacy practices.

    - Share information with family or friends involved in your care or payment for your care provided. You have the opportunity to agree or object to this disclosure. If you are unable to agree or object, we may disclose information as necessary based on our professional judgment.

    - For health oversights activities such as investigations, audits, and inspections as authorized by law.

    - For lawsuits and similar proceedings when we receive satisfactory assurance that appropriate precautions have been taken.

    - When requested by law enforcement as required by law or court order. - When otherwise required by law.

    TMJ Dental Health Center is Required By Law To:

    - Maintain the privacy of your health information.

    - Provide this notice that describes the ways we may use and share your information.

    - Follow the terms of the notice currently in effect.

    You Have The Right To:

    - Request restrictions on how we use and share your health information. We will consider all requests for restrictions carefully, but are not required to agree to any restrictions.

    - Inspect and copy your health information, including dental and billing records. Fees may apply. Under limited circumstances, we may deny your access to a portion of your health information and you may request a review of the denial. *

    Requests marked with a star (*) must be in writing.

    We reserve the right to change or privacy practices and to alter this Notice according to those changes; we will provide a copy of the changes to you at your next schedule appointment.

    I understand and agree to the above described privacy policy.

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After submitting, feel free to return to the Patient Forms page. Please note, there are multiple forms for each section.


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