The Health Insurance Portability & Accountability Act of 1996 HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, to be kept confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. �HIPAA" provides penalties for covered entities that misuse personal health information.

As required by �HIPPA�, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We use and disclose your medical records for the purposes of treatment, payment and health care operations.

• Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. And example of this would include teeth cleaning services.
  
  
• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
  
  
• Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer services. An example would be an internal quality assessment review.
  
  

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other heath-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying you your authorization.

You have certain rights in regards to your protected health information, which you may exercise by presenting a written request to our Privacy Officer at the practice address listed below:

• The right to request restrictions on certain uses and disclosures o protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
  
  
• The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
  
  
• The right to inspect and copy your protected health information.
  
  
• The right to amend your protected health information.
  
  
• The right to receive an accounting of disclosures of protected health information.
  
  
• The right to obtain a paper copy of this notice from us upon request.
  
  

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of April 14, 2003, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. Revisions to our Notice of Privacy Practices will be posted on the effective date and you may request a written copy of the Revised Notice from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health and Human Services, Office of Civil Rights about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.


Charles C. Nunnally, D.D.S.
3326 Forest Lane,
Dallas, TX 75234
972-488-2123


The U.S. Department of Health and Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
877-696-6775 (toll free)