THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GETACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY
I. Our Clinic: We are required to maintain the privacy of patient health information and to provide patients with anotice of our privacy practices. “We” and “our” means our clinic. “You” and “your” means the patient.
II. How to Contact Us/Our Privacy Official: If you have any questions or would like further information about this Notice, you can contact the privacy official(s) at:
Contact: Compliance Specialist
Telephone: 918-786-0017
E-mail: [email protected]
Address: 2500 S. Broadway, STE 350, Edmond, OK 73013
III. Our Promise to You and Our Legal Obligations: The privacy of your health information is important to us.
We understand that your health information is personal and we are committed to protecting it. This Notice
describes how we may use and disclose your protected health information to carry out treatment, payment
or health care operations and for other purposes that are permitted or required by law. It also describes
your rights to access and control your protected health information. Protected health information is
information about you, including demographic information, that may identify you and that relates to your
past, present or future physical or mental health or condition and related health care services.
We are required by law to:
• Maintain the privacy of your protected health information
•Give you this Notice of our legal duties and privacy practices with respect to that information
• Abide by the terms of our Notice that is currently in effect.
IV. Last Revision Date: This Notice was last revised on February 12, 2026
V. How We May Use or Disclose Your Health Information: The following examples describe different ways we may use or disclose your health information. These examples are not meant to be exhaustive. We are permitted by law to use and disclose your health information for the following purposes:
A. Common Uses and Disclosures
1. Treatment: We may use your health information to provide you with dental treatment or services, suchas cleaning or examining your teeth or performing dental procedures. We may disclose health
information about you to dental specialists, physicians, or other health care professionals involved in
your care.
2. Payment: We may use and disclose your health information to obtain payment from health plans and
insurers for the care that we provide to you.
3. Health Care Operations: We may use and disclose health information about you in connection with health
care operations necessary to run our practice, including review of our treatment and services, training,
evaluating the performance of our staff and health care professionals, quality assurance, financial or billing
audits, legal matters, and business planning and development.
4. Appointment Reminders: We may use or disclose your health information to contact you with appointment
reminders by mail, phone, voicemail, text, or email.
5. Treatment Alternatives and Health-Related Benefits and Services: We may use or disclose your health
information to inform you about treatment options, alternatives, or health-related benefits and services that
may be of interest to you.
6. Disclosure to Family Members and Friends: We may disclose your health information to a family member,
friend, or other person involved in your care or payment for your care, unless you object or we determine it
is not in your best interest to do so.
7. Disclosure to Business Associates: We may disclose your protected health information to our third-party
service providers (called, “business associates”) that perform functions on our behalf or provide us with
services if the information is necessary for such functions or services. For example, we may use a business
associate to assist us in maintaining our practice management software. All of our business associates are
obligated, under contract with us, to protect the privacy of your information and are not allowed to use or
disclose any information other than as specified in our contract.
B. Other Permitted and Required Uses and Disclosures
1. Disclosures Required by Law: We may use or disclose patient health information to the extent we are
required by law to do so. For example, we are required to disclose patient health information to the U.S.
Department of Health and Human Services so that it can investigate complaints or determine our compliance
with HIPAA.
2. Public Health Activities: We may disclose patient health information for public health activities and
purposes, which include: preventing or controlling disease, injury or disability; reporting births or deaths;
reporting child abuse or neglect; reporting adverse reactions to medications or foods; reporting product
defects; enabling product recalls; and notifying a person who may have been exposed to a disease or may
be at risk for contracting or spreading a disease or condition.
3. Victims of Abuse, Neglect or Domestic Violence: We may disclose health information to the appropriate
government authority about a patient whom we believe is a victim of abuse, neglect or domestic violence
4. Health Oversight Activities: We may disclose patient health information to a health oversight agency for
activities necessary for the government to provide appropriate oversight of the health care system, certain
government benefit programs, and compliance with certain civil rights laws.
5. Lawsuits and Legal Actions: We may disclose your health information in response to a court or
administrative order, or in response to a subpoena, discovery request, or other lawful process, provided that
applicable legal requirements are met.
6. Law Enforcement Purposes: We may disclose your health information to a law enforcement official for law
enforcement purposes, such as to identify or locate a suspect, material witness or missing person or to alert
law enforcement of a crime.
7. Coroners, Medical Examiners and Funeral Directors: We may disclose your health information to a coroner,
medical examiner or funeral director to allow them to carry out their duties.
8. Organ, Eye and Tissue Donation: We may use or disclose your health information to organ procurement
organizations or others that obtain, bank or transplant cadaveric organs, eyes or tissue for donation and
transplant.
9. Research Purposes: We may use or disclose your information for research purposes pursuant to patient
authorization waiver approval by an Institutional Review Board or Privacy Board
10. Serious Threat to Health or Safety: We may use or disclose your health information if we believe it is
necessary to do so to prevent or lessen a serious threat to anyone’s health or safety.
11. Specialized Government Functions: We may disclose your health information to the military (domestic or
foreign) about its members or veterans, for national security and protective services for the President or
other heads of state, to the government for security clearance reviews, and to a jail or prison about its
inmates.
12. Workers’ Compensation: We may disclose your health information to comply with workers’ compensation
laws or similar programs that provide benefits for work-related injuries or illness.
VI. Your Written Authorization for Any Other Use or Disclosure of Your Health Information: Uses and
disclosures of your protected health information that involve the release of psychotherapy notes (if any),
marketing, sale of your protected health information, or other uses or disclosures not described in this
notice will be made only with your written authorization, unless otherwise permitted or required by law.
You may revoke this authorization at any time, in writing, except to the extent that this office has taken an
action in reliance on the use of disclosure indicated in the authorization. If a use or disclosure of protected
health information described in this Notice is prohibited or materially limited by other applicable federal
or state laws, including laws governing substance use disorder records, we will comply with the more
stringent law.
VII. Your Rights with Respect to Your Health Information: You have the following rights with respect to certain
health information that we have about you (information in a Designated Record Set as defined by HIPAA). To exercise
any of these rights, you must submit a written request to our Privacy Official listed on the first page of this Notice
A. Right to Access and Review: You may request to access and review a copy of your health information. We may
deny your request under certain circumstances. You will receive written notice of a denial and can appeal it.
We will provide a copy of your health information in a format you request if it is readily producible. If not readily
producible, we will provide it in a hard copy format or other format that is mutually agreeable. If your health
information is included in an Electronic Health Record, you have the right to obtain a copy of it in an electronic
format and to direct us to send it to the person or entity you designate in an electronic format. We may charge
a reasonable fee to cover our cost to provide you with copies of your health information.
B. Right to Amend: If you believe that your health information is incorrect or incomplete, you may request that we amend it. We may deny your request under certain circumstances. You will receive written notice of a denial and can file a statement of disagreement that will be included with your health information that you believe is
incorrect or incomplete
C. Right to Restrict Use and Disclosure: You may request that we restrict uses of your health information to carry
out treatment, payment, or health care operations or to your family member or friend involved in your care or
the payment for your care. We may not (and are not required to) agree to your requested restrictions, with one
exception: If you pay out of your pocket in full for a service you receive from us and you request that we not
submit the claim for this service to your health insurer or health plan for reimbursement, we must honor that
request
D. Right to Confidential Communications, Alternative Means and Locations: You may request to receive
communications of health information by alternative means or at an alternative location. We will accommodate
a request if it is reasonable and you indicate that communication by regular means could endanger you. When
you submit a written request to the Privacy Official listed on the first page of this Notice, you need to provide
an alternative method of contact or alternative address and indicate how payment for services will be handled.
E. Right to an Accounting of Disclosures: You have a right to receive an accounting of disclosures of your health
information for the six (6) years prior to the date that the accounting is requested except for disclosures to carry
out treatment, payment, health care operations (and certain other exceptions as provided by HIPAA). The first
accounting we provide in any 12-month period will be without charge to you. We may charge a reasonable fee to
cover the cost for each subsequent request for an accounting within the same 12-month period. We will notify
you in advance of this fee and you may choose to modify or withdraw your request at that time.
F. Right to a Paper Copy of this Notice: You have the right to a paper copy of this Notice. You may ask us to give
you a paper copy of the Notice at any time (even if you have agreed to receive the Notice electronically). To
obtain a paper copy, ask the Privacy Official.
G. Right to Receive Notification of a Security Breach: We are required by law to notify you if the privacy or security
of your health information has been breached. The notification will occur by first class mail within sixty (60) days
of the event. A breach occurs when there has been an unauthorized use or disclosure under HIPAA that
compromises the privacy or security of your health information. The breach notification will contain the following
information: (1) a brief description of what happened, including the date of the breach and the date of the
discovery of the breach; (2) the steps you should take to protect yourself from potential harm resulting from the
breach; and (3) a brief description of what we are doing to investigate the breach, mitigate losses, and to protect
against further breaches.
VIII. Substance Use Disorder (SUD) Records: Certain health information related to substance use disorder (SUD)
treatment may be protected under federal law (42 C.F.R. Part 2), in addition to HIPAA. When applicable, SUD records are subject to stricter confidentiality protections than other types of protected health information and generally may not be used or disclosed without your written consent, except as permitted or required by law. You may provide a single written consent authorizing future uses and disclosures of your SUD information for treatment, payment, and health care operations.
A. Redisclosure Notice: Once disclosed under a valid consent, SUD information may be redisclosed by the
recipient in accordance with HIPAA and Part 2 requirements, except that SUD counseling or psychotherapy
notes require a separate consent.
B. Legal Protections: SUD records may not be used or disclosed in civil, criminal, administrative, or legislative
proceedings against you without your specific written consent or a court order, as permitted by law. Federal
law prohibits the use of SUD records to discriminate against you in health care, employment, housing, access
to courts, or other benefits.
C. Patient Rights: You have the right to receive information about how your SUD records are used and disclosed
and to request restrictions, where permitted by law.
D. Breach Notification & Complaints: If a breach of unsecured SUD information occurs, we will provide
notification in accordance with the HIPAA Breach Notification Rule. You may file a complaint regarding the use
or disclosure of your SUD records with our Privacy Official or with the U.S. Department of Health and Human
Services, Office for Civil Rights.
if your treatment involves SUD-related information and you have questions about these protections, you may contact our Privacy Official listed in this Notice.
IX. Special Protections for HIV, Alcohol and Substance Abuse, Mental Health and Genetic Information:
Certain federal and state laws may require special privacy protections that restrict the use and disclosure
of certain health information, including HIV-related information, alcohol and substance abuse information,
mental health information, and genetic information. For example, a health plan is not permitted to use or
disclose genetic information for underwriting purposes. Some parts of this HIPAA Notice of Privacy
Practices may not apply to these types of information. If your treatment involves this information, you may
contact our office for more information about these protections.
X. Our Right to Change Our Privacy Practices and This Notice: We reserve the right to change the terms of this
Notice at any time. Any change will apply to the health information we have about you or create or receive in the
future. We will promptly revise the Notice when there is a material change to the uses or disclosures, individual’s
rights, our legal duties, or other privacy practices discussed in this Notice. We will post the revised Notice on our
website (if applicable) and in our office and will provide a copy of it to you on request.
XI. How to Make Privacy Complaints: If you have any complaints about your privacy rights or how your health information has been used or disclosed, you may file a complaint with us by contacting our Privacy Official listed on the first page of this Notice. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you in any way if you choose to file a complaint.