What Is Protected Health Information (PHI)?

Protected Health Information (PHI) is information about you that:

• Identifies you (such as your name, address, phone number, or date of birth)

• Relates to your past, present, or future physical or mental health

• Relates to healthcare services you receive at our office

Your information may exist in written, electronic, or verbal form.

Pinecrest Orthodontics is required by law to maintain the confidentiality of your PHI and to follow the terms of this Notice.

3.. Lobby Poster English Notice…

Your Privacy Rights

Under the HIPAA Privacy Rule, you have the following rights:

1. Right to Receive a Copy of This Notice

You may request a paper or electronic copy of this Notice at any time. We are required to follow the terms outlined here.

3.. Lobby Poster English Notice…

If our privacy practices change, we will update this Notice and make the revised version available in our office and on our website.

2. Right to Authorize Other Uses or Disclosures

Any use or disclosure of your PHI not described in this Notice requires your written authorization.

For example, we would need your written permission for:

• Marketing purposes

• Most disclosures of psychotherapy notes

• The sale of PHI

You may revoke your authorization in writing at any time.

3.. Lobby Poster English Notice…

3. Right to Confidential Communication

You may request that we contact you:

• At a specific phone number

• At an alternative address

• By email

Please submit your request in writing. We will honor all reasonable requests.

3.. Lobby Poster English Notice…

4. Right to Inspect and Copy Your Records

You may inspect or obtain a copy of your complete health record.

If records are maintained electronically, you may request an electronic copy. We may charge a reasonable fee consistent with state and federal guidelines.

3.. Lobby Poster English Notice…

5. Right to Request Restrictions

You may request in writing that we restrict certain uses or disclosures of your PHI for:

• Treatment

• Payment

• Healthcare operations

We are not required to agree to all requests, but if we do, we will follow the restriction except in emergencies.

3.. Lobby Poster English Notice…

If you pay for a service in full out-of-pocket, you may request that we not disclose that information to your health plan. We are required to honor that request.

6. Right to Request Amendments

If you believe your information is incorrect or incomplete, you may request an amendment. In some cases, we may deny the request, but you will be notified in writing.

3.. Lobby Poster English Notice…

7. Right to Receive an Accounting of Disclosures

You may request a list of certain disclosures of your PHI made outside our office.

3.. Lobby Poster English Notice…

8. Right to Receive Breach Notification

If your unsecured PHI is compromised in a breach requiring notification, you will receive written notice.

3.. Lobby Poster English Notice…

How We May Use and Disclose Your Information

We may use or disclose your PHI without additional authorization for the following purposes:

Treatment

We may use your information to provide and coordinate your orthodontic care.

For example:

• Sharing information with another healthcare provider

• Coordinating with a pharmacy

• Referring to a specialist

3.. Lobby Poster English Notice…

Payment

We may use your PHI to obtain payment for services. This may include:

• Verifying insurance coverage

• Submitting claims

• Obtaining prior authorizations

3.. Lobby Poster English Notice…

Healthcare Operations

We may use your information for:

• Quality assessment and improvement

• Staff training

• Business planning

• Audits

• Legal services

• Patient safety activities

3.. Lobby Poster English Notice…

Appointment Reminders & Health Communications

We may contact you to:

• Remind you of appointments

• Provide test results

• Inform you about treatment options

• Share information about services offered by our office

You may opt out of certain communications.

3.. Lobby Poster English Notice…

Individuals Involved in Your Care

Unless you object, we may disclose relevant information to:

• A parent or guardian

• A family member

• A close friend involved in your care

If you are unable to agree or object, we may use professional judgment to determine what is in your best interest.

3.. Lobby Poster English Notice…

Other Permitted or Required Disclosures

We may disclose your PHI without authorization when required by law, including:

• Public health reporting

• Health oversight activities

• Abuse or neglect reporting

• Legal proceedings

• Law enforcement

• Workers’ compensation

• Military or national security purposes

• Compliance investigations by the U.S. Department of Health and Human Services

3.. Lobby Poster English Notice…

Substance Use Disorder Records (42 CFR Part 2)

Records related to substance use disorder treatment are protected under federal law (42 CFR Part 2). These records may not be disclosed without specific written consent except as permitted by law.

3.. Lobby Poster English Notice…

Filing a Privacy Complaint

If you believe your privacy rights have been violated, you may:

1. File a complaint with Pinecrest Orthodontics

2. File a complaint with the Secretary of the U.S. Department of Health and Human Services

We will never retaliate against you for filing a complaint.

3.. Lobby Poster English Notice…

To submit a privacy complaint or request more information:

Privacy Manager
Pinecrest Orthodontics
12197 S Dixie Hwy
Pinecrest, FL 33156
Phone: (Insert Office Phone)

Our Commitment to You

At Pinecrest Orthodontics, we’re proud to be Pinecrest’s only exclusively orthodontic practice—trusted by families since 2017.

Pinecrest Orthodontics _ Brand …

Protecting your health information is part of delivering the high-tech, high-comfort care you expect from us.

If you have any questions about your privacy rights, please contact our office. We’re happy to help.