Patient Privacy Policy 


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.

The Health Insurance Portability & Accountability Act of 1996 (”HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential.  This Act gives you, the patient, significant new rights to understand and control how your health information is used.  HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your Protected Health Information (PHI) and how we may use and disclose your health information.

This notice describes our Practice’s policies, which extend to:

  • Any health care professional authorized to enter information into your chart.
  • All areas of the Practice (front desk, administration, billing and collection, etc.).
  • All employees and other personnel that work for or with our Practice.
  • Our business associates (including a billing service, or facilities to which we refer patients).

Once you sign a Consent Form, we may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations.

  • Treatment means providing, coordination, or managing health care and related services by one or more health care providers.  Examples of this would be surgery, consultations, and referrals to other healthcare providers.
  • Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review.  An example of this would be sending a bill for your visit to your insurance company for payment.
  • Health care operations include the business aspects of running our practice, such as conducting quality assessment, auditing, credentialing, cost-management analysis, and customer service.  An example would be a review of patient charts that underwent a specific procedure for quality control.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may, without prior consent, use, or disclose PHI to carry out treatment, payment, or health care operations in the following circumstances:

  • In emergency treatment situations, if we attempt to obtain such consent as soon as reasonably practicable after the delivery of such treatment;
  • If we are required by law to treat you, and we attempt to obtain such consent but are unable to obtain such consent; or
  • If we attempt to obtain your consent but are unable to do so due to substantial barriers to communicating with you, and we determine that, in our professional judgment, your consent to receive treatment is clearly inferred from the circumstances.

 Other Disclosures and Uses:

  • Notification – Unless you object, we may use or disclose your PHI to notify, or assist in notifying a family member, personal representative or other person responsible for your care, about your location and general condition.
  • Communication with Family – Using our best judgment, we may disclose to a family member, friend, or any other person you identify, health information relevant to the person’s involvement in your care or in payment for such care.
  • Appointment and Patient Recall Reminders – We may use and disclose medical information to contact you as a reminder that you have an appointment for care with the Practice or that you are due to receive care from us.  This contact may be by phone, in writing, email or otherwise and may involve the leaving of an email, a message on an answering machine, or otherwise which could (potentially) be received or intercepted by others.
  • Workers Compensation – If you are seeking compensation through Workers Compensation, we may disclose your PHI to the extent necessary to comply with laws relating to Workers Compensation.
  • Abuse and Neglect – We may disclose your PHI to public authorities as allowed by law to report abuse or neglect.
  • Correctional Institutions/Law Enforcement – If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your PHI necessary for your health and the health and safety of other individuals.  In addition, we may disclose your PHI 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.

As a multiple doctor practice, it may be necessary to share your personal health information between doctors to facilitate your treatment and follow up care.  We will not sell or receive financial remuneration for release of your PHI without your written authorization.

Any other uses and disclosures will be made only with your written authorization.  You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your PHI, which you can exercise by presenting a written request to the Privacy Officer:

  • The right to request restrictions on certain uses and disclosures of PHI, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you.  We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
  • The right to request that we do not disclose your treatment information to any health plans if you pay out of pocket for your service.
  • The right to reasonable requests to receive confidential communications of PHI from us by alternative means or at alternative locations.
  • The right to inspect and obtain a paper or electronic copy of your PHI within 60 days.
  • The right to amend your PHI.
  • The right to receive an accounting of disclosures of PHI.
  • The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI.  We also must notify you in the event of a breach of unsecured PHI.  A breach exists when there is an impermissible use or disclosure of PHI.

We will, from time to time, have students of Dentistry, dental hygiene, dental and surgical assisting, observing surgery in our office.  If you specifically do not want an observer in your surgery, please make this known.

This notice if effective as of April 14, 2003, last being revised on September 18, 2013, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect.  We reserve the right to change the terms of our Notice of Privacy Practices currently in effect.  We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all PHI that we maintain. 

 We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. 

You have recourse if you feel that your privacy protections have been violated. You have the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office.  We will not retaliate against you for filing a complaint.


For more information about HIPAA or To file a complaint:

The U.S. Department of Health & Human Services

Office of Civil Rights                                                              

200 Independence Avenue, S.W.                                                       Please contact us for more information:

Washington, D.C.  20201                                                                   930 – 16th Avenue

(202) 619-0257                                                                                  Moline, Illinois     61265

Toll Free: 1-877-696-6775                                                                  River Valley Oral and Maxillofacial Surgery Phone Number 309-797-1770