Notice of Privacy Practices


OUR OBLIGATION TO YOU  We are committed to protecting the privacy of your medical information.  We are required by law to maintain the confidentiality of information that identifies you and the care you receive.  We are required to give you this Notice of our legal duties and privacy practices, and your rights, and to follow the terms of this Notice.  There are other laws that provide additional protections for medical information related to treatment for mental health, alcohol and other substance abuse, and HIV/AIDS.  We will follow the requirements of these laws for such medical information. 


TREATMENT  We may use or disclose your medical information to treat you.  For example, we give information to lab technicians, dental hygienists, and other dentists so that you may receive proper care. 

PAYMENT  We may use and disclose your medical information to receive payment.  For example, we may contact your insurer to verify what benefits you are eligible for or to submit a claim for payment. We may also use or disclose your medical information to obtain payment from third parties that may be responsible for payment, such as family members, and to bill you directly. 

HEALTHCARE OPERATIONS  We will use and disclose medical information for healthcare operations.  For example, we might give information to a quality review organization or we might use information for business planning. 

INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE  We may disclose medical information to a friend or family member who is involved in your care or payment, unless you ask us not to.  We may disclose information to disaster relief organizations, such as the Red Cross, so that your family can be notified about your condition and location. 


AS REQUIRED BY LAW,  but only to the extent and under the circumstances provided in such law. 

TO PUBLIC HEALTH AUTHORITIES, for activities such as keeping birth or death records, preventing or controlling communicable disease, injury or disability, ensuring the safety of drugs and medical devices, reporting child abuse, for workplace surveillance or work related illness and injury and similar purposes. 

TO REPORT ABUSE, NEGLECT OR DOMESTIC VIOLENCE TO GOVERNMENT AUTHORITIES, if we believe you may be a victim. We will tell you in advance if permitted by law unless we think that telling you would place you at risk of serious harm. We will not inform your personal representative if we believe that would not be in your best interests. 

FOR HEALTH OVERSIGHT ACTIVITIES, to health oversight agencies for activities authorized by law, including audits, civil, administrative or criminal investigations, licensure or disciplinary actions, and monitoring of compliance with law. 

IN JUDICIAL AND ADMINISTRATIVE PROCEEDINGS, in response to court or administrative orders, or in response to subpoenas, discovery requests or other lawful process after reasonable efforts to notify you or obtain a protective order. 

TO LAW ENFORCEMENT, to identify or locate suspects, fugitives or witnesses, or victims of crime (with your consent in some circumstances), to report deaths from crime, crimes on the premises, or, in emergencies, the commission of a crime. 

TO CORONERS, MEDICAL EXAMINERS, FUNERAL DIRECTORS, to identify a deceased person, determine the cause of death, or as reasonably necessary to permit them to carry out their duties. 

TO ORGAN PROCUREMENT ORGANIZATIONS, that handle organ procurement, eye or tissue transplantation or to an organ donation and transplantation. 

FOR RESEARCH PURPOSES, to the extent we have met the standards and requirements set by law and regulation to protect confidentially and the rights of individuals in the context of research.  

TO PREVENT A SERIOUS THREAT TO HEALTH OR SAFETY, to the target of a threat, to someone in a position to prevent it, or to law enforcement officials if you admit to a violent crime or have escaped from jail.

MILITARY AND VETERENS, to command authorities, if you are in the armed forces.

FOR NATIONAL SECURITY, INTELLIGENCE ACTIVITIES, PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS, AND STATE DEPARTMENT PURPOSES, to authorized officials as authorized by law to perform their duties and conduct investigations or make medical suitability determinations relating to service in the Department of State.

TO CORRECTIONAL INSTITUTIONS, for inmates, information for your health and the health and safety of others.

FOR WORKERS COMPENSATION or similar programs, as required by the laws governing these programs. 

WITH YOUR AUTHORIZATION We may use or disclose medical information for purposes not described in this Notice or otherwise permitted by law only with your written authorization.  You may revoke any authorization at any time, in writing, but only as to future uses or disclosures, and only where we have not already acted in reliance on your authorization.

To exercise these rights see the contact information below

The Right to Obtain a Copy of this Notice of Privacy Practices  We will provide you with a copy of the current Notice of Privacy Practices upon your request. 

The Right to Request a Restriction on Certain Uses and Disclosures  You have the right to request restrictions on certain uses and disclosures of your medical information described above.  We are not required to agree with your request.  If we do agree with the request, we will comply with your request except to the extent that disclosure has already occurred or if  you are in need of emergency treatment and the information is needed to provide the emergency treatment.

The Right to Inspect and Request a Copy of Your Health Record  You may inspect an obtain a copy of your health record except in limited circumstances defined by federal regulations.  We are permitted to charge a reasonable cost-based fee if you ask for a copy of your record. 

The Right to Request an Amendment to Your Health Record
​You may request an amendment to your health record.  Your request must be in writing and include a reason to support the request.  We may deny your request if for certain reasons, including if we determine that the information, as documented, is accurate and complete.  If we deny your request to amend we will explain our denial and what other options you have.

The Right to Obtain an Accounting of Disclosures of Your Health Information  You may request an accounting of the disclosures we have made of your health information.  The accounting will only provide information about disclosures made for purposes other than treatment, payment or healthcare operations; disclosures to you or authorized by you; disclosures incidental to permitted disclosures, and certain other disclosures excluded by regulation. 

The Right to Request Communication of Your Health Information by Alternative Means or Locations  You have the right to request that we communicate with you by alternate means (e.g. fax versus mail) or at alternative locations (alternate address or phone number).  Your request must be in writing.  We will honor your request if it is reasonable. 

CONTACT  To exercise any of the rights described above, or if you have any questions about this Notice, please contact our Privacy Office, at Schwalbe Family Dentistry, 1807 Woodfield Dr., Savoy, IL , 61874, 217-351-9096.  If you believe your privacy rights have been violated, you may file a complaint with us, also at the above location.  You also have the right to complain to the Secretary of the Department of Health and Human Services, Office of Civil RIghts.  You can obtain contact information to file a complaint with the government from the contact listed above. We will not retaliate against you in any way for filing any type of complaint. 

CHANGES TO THIS NOTICE  We reserve the right to change this Notice.  We reserve the right to make the revised or changed Notice effective for information we already have about you as well as any information we receive in the future.  We will post a copy of the current Notice in our facility and a copy of the current Notice in effect will be available at the registration area of our facility. 
EFFECTIVE DATE   April 14, 2003