This Notice describes the privacy practices of Southard Family Dental “We” and “our” means the Dental Practice. “You” and “your” means our patient.
If you have any questions or would like further information about this Notice, you can contact Southard Family Dental at:
6139 E 91st St Tulsa, Ok. 74137
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:
This Notice was last revised on November 16th, 2021.
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:
1. Treatment: We may use your health information to provide you with dental treatment or services, such as 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 when contacting you to remind you of a dental appointment. We may contact you by using a postcard, letter, phone call, voice message, text or email.
5. Treatment Alternatives and Health-Related Beneﬁts and Services: We may use and disclose your health information to tell you about treatment options or 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 or friend who is involved with your care or payment for your care if you do not object or, if you are not present, we believe it is 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.
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 patient health information in response to (i) a court or administrative order or (ii) a subpoena, discovery request, or other lawful process that is not ordered by a court if efforts have been made to notify the patient or to obtain an order protecting the information requested.
6. Law Enforcement Purposes. We may disclose your health information to a law enforcement ofﬁcial for a 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.
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 above in this notice is prohibited or materially limited by other laws that apply to use, we intend to meet the requirements of the more stringent law.
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.
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.
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.
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.
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.
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
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.
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.
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.
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. The effective date of this Notice is May 20th, 2019.
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.
By signing my name below, I certify that I have read the above information. Any questions concerning these policies have been discussed. My signature also certiﬁes my understanding of and agreement with the above policies. I may request a copy of this document upon request:
Last Edited on 2021-11-16
We may collect information about you in a variety of ways. The information we may collect on the Site includes:
Personally identifiable information, such as your name, shipping address, email address, and telephone number, and demographic information, such as your age, gender, hometown, and interests, that you voluntarily give to us [when you register with the Site] or when you choose to participate in various activities related to the Site, such as online chat and message boards. You are under no obligation to provide us with personal information of any kind, however your refusal to do so may prevent you from using certain features of the Site.
Information our servers automatically collect when you access the Site, such as your IP address, your browser type, your operating system, your access times, and the pages you have viewed directly before and after accessing the Site.
The Site may by default access your Facebook basic account information, including your name, email, gender, birthday, current city, and profile picture URL, as well as other information that you choose to make public. We may also request access to other permissions related to your account, such as friends, check ins, and likes, and you may choose to grant or deny us access to each individual permission. For more information regarding Facebook permissions, refer to the Facebook Permissions Reference page.
User information from social networking sites, such as [Apple’s Game Center, Facebook, Google+, Instagram, Pinterest, Twitter], including your name, your social network username, location, gender, birth date, email address, profile picture, and public data for contacts, if you connect your account to such social networks.
Device information, such as your mobile device ID, model, and manufacturer, and information about the location of your device, if you access the Site from a mobile device.
Information from third parties, such as personal information or network friends, if you connect your account to the third party and grant the Site permission to access this information.
Personal and other information you may provide when entering contests or giveaways and/or responding to surveys.
Having accurate information about you permits us to provide you with a smooth, efficient, and customized experience. Specifically, we may use information collected about you via the Site to:
Administer sweepstakes, promotions, and contests.
Assist law enforcement and respond to subpoena.
Compile anonymous statistical data and analysis for use internally or with third parties.
Create and manage your account.
Deliver targeted advertising, coupons, newsletters, and other information regarding promotions and the Site to you.
Email you regarding your account or order.
Enable user-to-user communications.
Fulfill and manage purchases, orders, payments, and other transactions related to the Site.
Generate a personal profile about you to make future visits to the Site more personalized.
Increase the efficiency and operation of the Site .
Monitor and analyze usage and trends to improve your experience with the Site.
Notify you of updates to the Site.
Offer new products, services, and/or recommendations to you.
Perform other business activities as needed.
Prevent fraudulent transactions, monitor against theft, and protect against criminal activity.
Process payments and refunds.
Request feedback and contact you about your use of the Site.
Resolve disputes and troubleshoot problems.
Respond to product and customer service requests.
Send you a newsletter.
Solicit support for the Site.
We may share information we have collected about you in certain situations. Your information may be disclosed as follows:
If we believe the release of information about you is necessary to respond to legal process, to investigate or remedy potential violations of our policies, or to protect the rights, property, and safety of others, we may share your information as permitted or required by any applicable law, rule, or regulation. This includes exchanging information with other entities for fraud protection and credit risk reduction.
We may share your information with third parties that perform services for us or on our behalf, including payment processing, data analysis, email delivery, hosting services, customer service, and marketing assistance.
With your consent, or with an opportunity for you to withdraw consent, we may share your information with third parties for marketing purposes, as permitted by law.
If you interact with other users of the Site, those users may see your name, profile photo, and descriptions of your activity, including sending invitations to other users, chatting with other users, liking posts, following blogs.
When you post comments, contributions or other content to the Site, your posts may be viewed by all users and may be publicly distributed outside the Site in perpetuity.
We may use third-party advertising companies to serve ads when you visit the Site. These companies may use information about your visits to the Site and other websites that are contained in web cookies in order to provide advertisements about goods and services of interest to you.
We may share your information with our business partners to offer you certain products, services or promotions.
If you connect to the Site through a social network, your contacts on the social network will see your name, profile photo, and descriptions of your activity.
We may share your information with advertisers and investors for the purpose of conducting general business analysis. We may also share your information with such third parties for marketing purposes, as permitted by law.
We are not responsible for the actions of third parties with whom you share personal or sensitive data, and we have no authority to manage or control third-party solicitations. If you no longer wish to receive correspondence, emails or other communications from third parties, you are responsible for contacting the third party directly.
You should be aware that getting a new computer, installing a new browser, upgrading an existing browser, or erasing or otherwise altering your browser’s cookies files may also clear certain opt-out cookies, plug-ins, or settings.
We use administrative, technical, and physical security measures to help protect your personal information. While we have taken reasonable steps to secure the personal information you provide to us, please be aware that despite our efforts, no security measures are perfect or impenetrable, and no method of data transmission can be guaranteed against any interception or other type of misuse. Any information disclosed online is vulnerable to interception and misuse by unauthorized parties. Therefore, we cannot guarantee complete security if you provide personal information.
We do not knowingly solicit information from or market to children under the age of 13. If you become aware of any data we have collected from children under age 13, please contact us using the contact information provided below.
You may at any time review or change the information in your account or terminate your account by:
Logging into your account settings and updating your account
Contacting us using the contact information provided below
If you no longer wish to receive correspondence, emails, or other communications from us, you may opt-out by:
Logging into your account settings and updating your preferences.
If you no longer wish to receive correspondence, emails, or other communications from third parties, you are responsible for contacting the third party directly.
California Civil Code Section 1798.83, also known as the “Shine The Light” law, permits our users who are California residents to request and obtain from us, once a year and free of charge, information about categories of personal information (if any) we disclosed to third parties for direct marketing purposes and the names and addresses of all third parties with which we shared personal information in the immediately preceding calendar year. If you are a California resident and would like to make such a request, please submit your request in writing to us using the contact information provided below.
If you are under 18 years of age, reside in California, and have a registered account with the Site, you have the right to request removal of unwanted data that you publicly post on the Site. To request removal of such data, please contact us using the contact information provided below, and include the email address associated with your account and a statement that you reside in California. We will make sure the data is not publicly displayed on the Site, but please be aware that the data may not be completely or comprehensively removed from our systems.
Southard Family Dental
6139 E 91st St Tulsa, Ok. 74137
Last updated 2022-4-26