Sealants for Smiles Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW DENTAL AND MEDICAL INFORMATION ABOUT YOUR CHILD 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 our Privacy Officer at the number listed at the end of this Notice.

Each time your child is seen by Sealants for Smiles, a record of this visit is made. Typically, this record contains an oral health status based upon a visual examination, a dental sealant treatment plan, a visual assessment of individual teeth, and billing-related information. This Notice applies to all of the records of your child’s care generated by Sealants for Smiles dentists and dental hygienists.

Our Responsibilities

Sealants for Smiles is required by law to maintain the privacy of your child’s health information and to provide you with a description of your legal duties and privacy practices regarding your health information. The current Notice will be posted on our website at www.sealantsforsmiles.org.  The notice will include the effective date. In addition, we will make our best effort to provide you with a copy of this notice that we request you acknowledge with your signature.

We are required by law to abide by the terms of this Notice and notify you if we make changes to this Notice, which may be at any time. Changes to the Notice will apply to your dental and medical information that we already maintain as well as new information received after the change occurs. If we change our Notice, it will be posted on our website at www.sealantsforsmiles.org.  You may also request that a revised Notice be sent to you in the mail. This Notice will also serve to advise you as to your rights with regard to your child’s dental and medical information.

How We May Use and Disclose Dental and Medical Information About Your Child.

The following categories describe examples of the way we use and disclose dental and medical information:

For Treatment: We may use dental and medical information about your child to provide, coordinate and manage your child’s treatment or services. We may disclose medical and dental information about your child to other dentists, doctors, school nurses, principals or other personnel who are involved in your child’s care. For example, a school nurse may need to know information about your child’s oral health status. We may also provide a subsequent healthcare provider with copies of various reports that should assist him or her in treating your child. For example, your medical and dental information may be provided to a dentist to whom your child has been referred so as to ensure that the dentist has appropriate information regarding your child’s previous treatment and diagnosis.

For Payment: We may use and disclose dental and medical information about your child’s treatment and services to bill and collect payment from Medicaid, your insurance company or a third party payer. For example, we may need to give Medicaid your child’s information before it approves or pays for the health care services we provided for your child.

For Health Care Operations: We may use or disclose, as needed, your child’s health information in order to support our business activities. These activities may include, but are not limited to, quality assessment activities, employee review activities, licensing, marketing, legal advice, accounting support, billing and collections and conducting or arranging for other business activities. We may also call your child by name in school classrooms when Sealants for Smiles dentists or dental hygienists are ready to see your child.

Business Associates: There are some services provided in our organization through contracts with business associates. Examples include quality assurance, accounting, legal services, and insurance billing services. When these services are contracted, we may disclose your child’s health information to our business associate(s) so that they can perform the job that we have asked them to do and bill Medicaid or your third-party payer for services rendered. To protect your child’s health information, however, we require the business associate to appropriately safeguard your child’s information through a written contract.

Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object.

We also may use and disclose your child’s health information as set forth below. You have the opportunity to agree or object to the use or disclosure of all or part of your child’s health information in these instances. If you are not present or able to agree or object to the use or disclosure of the health information (such as in an emergency situation), then the Sealants for Smiles dental professional may, using professional judgment, determine whether the disclosure is in your child’s best interest. In this case, only the information that is relevant to your child’s health care will be disclosed. In addition, we may disclose dental and medical information about your child to an entity assisting in a disaster relief effort so that your child’s family can be notified about your child’s condition, status and location.

We may use or disclose your child’s health information in the following situations without your authorization or without providing you with an opportunity to object. These situations include:

As required by law. We may use and disclose health information to the following types of entities, including but not limited to:

  • Food and Drug Administration
  • Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability
  • Correctional Institutions
  • Workers Compensation Agents 
  • Organ and Tissue Donation Organizations
  • Military Command Authorities
  • Health Oversight Agencies 
  • Funeral Directors, Coroners and Dental and Medical Directors
  • National Security and Intelligence Agencies 
  • Protective Services for the President and Others
  • Authority that receives reports on abuse and neglect 
  • Law Enforcement/Legal Proceedings: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. 
  • State-Specific Requirements: Many states have requirements for reporting including population-based activities relating to improving health or reducing health care costs.

Your Health Information Rights

Although your child’s health record is the physical property of Sealants for Smiles that compiled it, you have the right to:

Inspect and Copy: You have the right to inspect and copy dental and medical information that may be used to make decisions about your child’s care. We ask that you submit these requests in writing. Usually, this includes dental and medical and billing records, but does not include information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. We may deny your request. We will comply with the outcome or the review. Requests for access to and copies of your child’s dental and medical information must be submitted to Sealants for Smiles in writing.

Amend: If you feel that dental and medical information we have about your child is incorrect or incomplete, you may ask us to amend the information by submitting a request in writing. You have the right to request an amendment for as long as we keep the information. We may deny your request for an amendment, and if this occurs, you will be notified of the reason for the denial.

An Accounting of Disclosures: You have the right to request an accounting of our disclosures of dental and medical information about your child except for certain circumstances, including disclosures for treatment, payment, health care operations or where you specifically authorized a disclosure. Sealants for Smiles will provide the first accounting to you in any 12-month period without charge. Sealants for Smiles may impose a fee of $10.00 each subsequent request for an accounting within the 12-month period. We ask that you submit these requests in writing.

Request Restrictions: You have the right to request a restriction or limitation on the dental and medical information we use or disclose about your child’s treatment, payment or health care operations. You also have the right to request a limit on the dental and medical information we disclose about your child to someone who is involved in your child’s care or the payment for his/her care, like a family member or friend. For example, you could ask that we not use or disclose information about a procedure that your child had. We ask that you submit these requests in writing.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide your child with emergency treatment.

Request Confidential Communications: You have the right to request that we communicate with you about dental and medical matters in a certain way or at a certain location. We will agree to the request to the extent that it is reasonable for us to do so. For example, you ask that we use an alternative address for mailing information. We ask that you submit these requests in writing.

A Paper Copy of This Notice: You have a right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To exercise any of your rights, please obtain the required forms from the Privacy Officer and submit your request in writing.

Complaints:

If you believe you privacy rights have been violated, you may file a complaint with us by calling (801) 313-7097 and asking for the Privacy Officer or by contacting the Secretary of the Federal Department of Health and Human Services. All complaints must be also submitted in writing. You or your child will not be penalized for filing a complaint.

Other Uses of Dental and Medical Information:

Other uses and disclosures of dental and medical information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose dental and medical information about your child, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose dental and medical information about your child for the reasons covered by your written authorization. However, we are unable to take back any disclosures we have already made with your permission and we are required to retain our records of the care that we provided to you.

Privacy Officer: Dr. Roger J. Adams

Telephone Number: (801) 313-7097