Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Summary

This notice provides a summary of your rights, the choices you have regarding your health information, and how we may use and disclose your protected health information (PHI).

• Your Rights: You have the right to access, correct, and receive an accounting of disclosures of your PHI. You may also request restrictions on how your information is used and disclosed.
• Your Choices: You can make choices about how we communicate with you and whether we share your information with family members or others involved in your care.
• Our Uses and Disclosures: We may use and disclose your PHI for treatment, payment, and health care operations. Other uses require your written authorization unless permitted or required by law.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get a Copy of Your Health Information

You can ask to see or get a copy of your health and claims records and other health information we have about you. We will provide a copy or a summary of your health information, usually within 30 days of your request. You may request your records in paper or electronic format. We may charge a reasonable, cost-based fee.

Ask Us to Correct Your Health Information

You can ask us to correct health information about you that you think is incorrect or incomplete. We may say "no" to your request, but we'll tell you why in writing within 60 days of receiving your request.

Request Restrictions on Uses and Disclosures

You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information with your health insurer for the purpose of payment or health care operations, and we will honor that request.

Get a List of Those with Whom We've Shared Information

You can ask for a list (an accounting) of the times we've shared your health information for purposes other than treatment, payment, and health care operations, and certain other activities for the six years prior to the date you ask. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures. We'll provide one accounting per year for free but will charge a reasonable, cost-based fee if you ask for another within 12 months.

Request Confidential Communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will consider all reasonable requests and will say "yes" if you tell us you would be in danger if we do not.

Choose Someone to Act for You

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

Get a Copy of This Notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

File a Complaint

If you feel your rights are being violated or that we have violated your privacy, you may file a complaint with our practice or with the U.S. Department of Health and Human Services (HHS) Office for Civil Rights. You may file a complaint online at www.hhs.gov/ocr/privacy/hipaa/complaints/, by calling 1-877-696-6775, or by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201. We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

How We Communicate with You

You may ask us to communicate with you by alternative means or at alternative locations. For example, you may prefer we call you at a different phone number or send correspondence to a different address.

Sharing Information with Family and Friends

We may disclose your health information to a family member, friend, or other person you identify as being involved in your care or payment for your care. We may also share information about you in a disaster relief situation. If you are unable to tell us your preference (for example, if you are unconscious), we may use our professional judgment to decide whether sharing information is in your best interest.

Disaster Relief

We may share your health information with disaster relief organizations so that your family, friends, or others involved in your care can be notified of your location and condition.

Marketing

We will not use or share your health information for marketing purposes without your written authorization. You may revoke any authorization you provide at any time by submitting a written revocation to our office.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will provide you with a copy of this notice so you know how we use and share your health information.
• We will follow the terms of the notice that is currently in effect.
• We will notify you promptly if a breach occurs that may have compromised the privacy or security of your information.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Uses and Disclosures for Treatment, Payment, or Health Care Operations

Treatment

We may use and share your health information to provide, coordinate, or manage your oral surgery care. For example, we may share your information with your referring dentist, specialists, or anesthesiologists involved in your care so they have the information they need to treat you.

Payment

We may use and share your health information to bill and receive payment for the services we provide. For example, we may share information about you with your dental insurance plan or health plan so it will pay for your treatment.

Health Care Operations

We may use and share your health information for our practice operations, including quality improvement activities, staff training, practice management, and audits. These activities are necessary for us to run our practice and to make sure our patients receive quality care.

Other Uses and Disclosures

We may use or share your health information in the following situations without your authorization:

Business Associates

We may share your information with third parties who perform services on our behalf, such as billing companies, auditing firms, and legal counsel. These business associates are required to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Electronic Data Exchanges and Health Information Exchanges

We may participate in health information exchanges (HIEs) and share your health information electronically to facilitate treatment, payment, and health care operations.

As Required by Law

We will share information about you if state or federal law requires it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

Public Health and Safety

We may share health information about you for certain public health activities, including:

• Preventing disease and reporting adverse reactions to medications
• Reporting suspected child abuse or neglect
• Reporting vital events such as births and deaths
• Notifying the FDA about problems with products
• Preventing or reducing a serious threat to anyone's health or safety

Legal Proceedings

We may share health information about you in response to a court or administrative order, or in response to a subpoena, discovery request, or other lawful process.

Research

We may use or share your information for health research when an institutional review board or privacy board has reviewed the research proposal and approved a waiver of authorization.

Medical Examiners, Funeral Directors, and Coroners

We may share health information with a coroner, medical examiner, or funeral director when an individual dies.

Workers' Compensation

We may share health information about you for workers' compensation claims.

Law Enforcement and Government Requests

We may share health information with law enforcement officials for law enforcement purposes, to identify or locate a suspect, fugitive, witness, or missing person, or about a crime victim. We may also share information with authorized federal officials for intelligence, counterintelligence, and other national security activities.

Organ Donation

We may share health information about you with organ procurement organizations.

Military and Veterans

If you are a member of the armed forces, we may release your information as required by military command authorities.

Uses Requiring Your Written Authorization

We will not use or share your health information without your written authorization for the following purposes:

• Marketing purposes
• Sale of your protected health information
• Most uses of psychotherapy notes

You may revoke an authorization in writing at any time. Your revocation will not affect any uses or disclosures that occurred before we received your revocation.

Substance Use Disorder Records

In accordance with 42 CFR Part 2 and the 2024 HIPAA Privacy Rule Final Rule, records related to substance use disorder (SUD) treatment receive additional federal protections. If we maintain SUD treatment records, the following apply:

• You may provide a single consent for all future uses and disclosures of SUD records for treatment, payment, and health care operations purposes.
• You may revoke this consent in writing at any time.
• SUD records may not be used in civil, criminal, administrative, or legislative proceedings against you without your specific written consent or a court order.
• Information disclosed from SUD records may be re-disclosed by the recipient and may no longer be protected by federal confidentiality rules.
• We will not use SUD records for marketing or fundraising without providing you a clear opportunity to opt out.

Data Breach Notification

We will notify you within the legally required timeframe if a breach of unsecured protected health information is discovered that compromises the privacy or security of your information. Notification will be made in accordance with applicable federal and state law.

Scope of This Notice

This notice applies to all protected health information we generate and maintain, as well as all PHI you provide to us. All employees, staff, volunteers, trainees, and other members of our workforce follow the terms of this notice.

Changes to This Notice

We may change the terms of this notice at any time. A new notice will be effective for all protected health information that we maintain at that time. The current notice will be available upon request, in our office, and on our website.

Applicable Law

Where Tennessee state law provides greater protections for your health information than HIPAA, we will follow the stricter state requirements.

Contact Information

If you have questions about this notice, want to exercise any of your rights, or wish to file a complaint, please contact us:

Cookeville Oral Surgery
219 N Oak Ave, Cookeville, TN 38501
Phone: (931) 201-9922
Email: records@cookevilleos.com

See also our Privacy Policy, Terms of Use, and Accessibility Statement.