Privacy Practices

How medical information about you may be used and disclosed, and how you can access it

Notice of Privacy Practices

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. If you have any questions about this notice, please contact the Privacy Officer at 704.633.2612 (Salisbury) or 336.753.1305 (Mocksville).

The Health Insurance Portability and Accountability Act of 1966 (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 confidential. This Act gives you, the patient, significant rights to understand and control how your personal health information (PHI) is used. HIPAA provides penalties for covered entities that misuse PHI.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your PHI and how we may use and disclose your PHI. We may change this Notice of Privacy Practices at any time. Any changes will apply to all PHI. When changes to the notice occur, we will post the revised version in our office and on our website at A copy of the most recent notice will be given to you, upon request.

We may use and disclose your PHI only for each of the following purposes: treatment, payment, and health care operations.

  • Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include teeth cleaning services or referral to another practice.
  • 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 or x-rays from your visit to your insurance company for payment.
  • Health care options include the business aspect of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis, and customer service. An example would be internal assessment review.

We may post daily schedules, via computer terminals, in operatories. These schedules may include the patient’s name and reason for the appointment.

We may take digital images as part of your treatment. These images are for clinical use only. Identifiable images will not be shared without your consent, other than for payment or treatment purposes. We may contact you to provide appointment reminders, information about treatment alternatives, or other health-related benefits and services that may be of interest to you. This includes reminders about medication, if necessary. We may contact you by phone, at the number(s) provided by you, and with your consent. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing. We are required to honor and abide by such 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 request to the Privacy Officer:

  • The right to request restriction 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. However, we are 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 reasonable requests to receive confidential communications of PHI.
  • The right to inspect and copy your PHI.
  • The right to amend your PHI.
  • The right to receive an accounting disclosures of PHI.
  • The right to obtain a paper copy of this notice, upon request.

By law, we are required to maintain the privacy of your PHI, and provide you with notice of our legal duties and privacy practices with respect to personal health information. We may use and disclose your PHI in other situations without your permission, if required by law.

This notice is effective as of January 1, 2017. 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 and to make the new notice provisions effective for all PHI that we maintain. The most current copy of this notice will be posted. You may also request a copy of this notice from our office.

You have recourse, if you feel that your privacy protection has been violated. You have the right to file a written complaint with our office, with the Department of Health & Human Services Office of Civil Rights, about any violation of the provisions of this notice, or the policies and procedures of our offices. We will not retaliate against you for filing a complaint.

If you have any questions, please contact our office.

For more information about HIPAA, or to file a complaint, please call 292-619-0257 or 877-696-6775, or write to:

The U.S. Department of Health and Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201