NOTICE OF PRIVACY PRACTICE

WHO WILL FOLLOW THIS NOTICE: The Destiny Dental Affiliated Covered Entity (“Destiny Dental”) follows this Notice. An Affiliated Covered Entity is a group of Covered Entities and Health Care Providers under common ownership or control that designates itself as a single entity for purposes of compliance with the Health Insurance Portability and Accountability Act (“HIPAA”). The members of the Destiny Dental ACE will share Protected Health Information (“PHI”) with each other for the treatment, payment, and health care operations of the Destiny Dental ACE and as permitted by HIPAA and this Notice. The organizations that form Destiny Dental ACE are:

• D2 Dental of Hammond, P.C.
• D2 Dental of Lansing, P.C.
• D2 Dental of Illinois, P.C.
• D2 Dental of Michigan, P.C.
• D2 Dental of Wisconsin, S.C.

If you would like more information, please contact the Privacy Officer.

WE ARE REQUIRED BY LAW TO:

• Make certain that health information which identifies you is kept private
• Provide you with notice of your rights and our legal duties and privacy practices with respect to your health information
• Comply with this Notice of Privacy Practices
• Communicate any changes in this notice to you

INFORMATION THAT IS COVERED BY THIS NOTICE IS:

• Health care information about your treatment
• Billing and payment information
• Certain personal information needed to identify you, contact you, and provide for payment
• Oral, paper, and electronic information
• Information that is created, received, accessed, transmitted, and stored by us

PERSONS WHO MUST FOLLOW THIS NOTICE ARE:

• All locations, departments, and units of Provider (locations are available on our website at www.destinydentalcare.com)
• All employees, staff, and other office personnel
• Any volunteers or health care students, interns, residents, or fellows
• Any person or company providing services under Provider’s direction and control will follow the terms of this notice.

WE ARE PERMITTED TO USE AND DISCLOSE YOUR HEALTH INFORMATION FOR:

• Treatment: We may use your health information to provide, coordinate, or manage your dental treatment or services. We may disclose your dental information to dentists, dental hygienists, dental students, or other Provider employees or contractors who are involved in providing health care to you. For example, we may share your health information with another provider for a consultation or referral for further treatment.
• Payment: We may use and disclose your information to bill for dental treatment and services and receive payment from you, insurance companies, or third parties. For example, we may need to give information to your health plan about dental services you received so that your health plan will pay us or reimburse you for the procedure. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
• Health Care Operations: We may use and disclose information about you for our health care operations. These are functions that are necessary to operate our business, such as accounting and general administrative business functions, and that are necessary to ensure that patients receive quality care, such as evaluating the performance of staff and dentists who provide your health care.

USES OR DISCLOSURES TO WHICH YOU MAY OBJECT OR OPT OUT:

• Directory: We may include certain limited information in a directory (including name, location, and/or condition described in general terms) and this may be made available to others who request you by name.
• Immunization: We may provide proof of immunization to a school that is required by state or other law to have such proof.
• Persons involved in your care or responsible for payment: We may disclose information to a family member, relative, friend, or other identified person, prior to or after your death, who is involved in your care or payment for care unless you object in writing.
• Email or text: We may communicate with you by encrypted email or text unless you object.
• Fundraising: We will notify you if we intend to use your medical information for fundraising purposes and let you know that you have the right to opt out of receiving fundraising communications.

USES AND DISCLOSURES WHICH REQUIRE YOUR AUTHORIZATION:
Other uses and disclosures not covered in this notice will be made only with your written authorization. Authorization is required and, except in limited situations, may be revoked in writing at any time. The following require authorization which may not be revoked:

• Marketing: Disclosure of your information for marketing of products or services or treatment alternatives, including any subsidized treatment communications, that may be of benefit to you when we receive direct payment from a third party for making such communications, other than as set forth above regarding face-to-face communications and promotional gifts of nominal value.
• Sale of Protected Health Information unless an exception is met.

YOUR RIGHTS REGARDING YOUR DENTAL HEALTH INFORMATION: You have the right, subject to certain conditions, to:

• Right to request restrictions: You have the right to request, in writing, a restriction on uses and disclosures of your health information made for payment or health care operations. We are not always required to agree to a requested restriction. Restrictions to which we agree will be documented and followed. Agreements for restrictions may, however, be terminated under applicable circumstances (e.g., emergency treatment). You may request a restriction on the medical information we disclose to your family or friends. However, as set out above, in an emergency, disaster, or if you are not able to communicate, we may disclose information if, in our professional judgment, disclosure is necessary. We must agree to your request to restrict disclosure of medical information about you to a health plan if the medical information relates to a health care item or service for which you or someone on your behalf has paid in full. It is your responsibility to notify other health care providers of this restriction, such as in the case of a referral for follow-up services.
• Right to request confidential communications: You may request to receive communications from us in a certain method or at a certain location. For example, you may request that we contact you only at work, by email, or by mailed paper. We do not require an explanation for the request and will attempt to honor reasonable requests. If you request your medical information to be transmitted directly to another person designated by you, your written request must be signed and clearly identify the designated person and where the copy of Protected Health Information is to be sent.
• Right to access, inspect, and obtain copies of health information: You have the right to access, inspect, and receive a copy of your health information, including billing records, information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding, or other limited circumstances. Your request for a copy must be in writing. We may charge a reasonable, cost-based fee that includes only the cost of labor for copying, supplies, postage (if applicable), and preparing an explanation or summary (if requested) of the health information. If health information is maintained electronically and you request an electronic copy, we will provide access in the electronic format you request, if available, or if not, in a readable electronic form and format mutually agreed upon. If we deny access to your health information, you will receive a timely, written denial in plain language that explains the basis for the denial, your review rights, and an explanation of how to exercise those rights.

• Right to request amendment: You have the right to request, in writing, an amendment of your record and include the reason for your request. We will respond within sixty (60) days of receipt of the request and may extend the time for such action by up to thirty (30) days if, within the initial sixty (60) days, we provide you with a written explanation of the reasons for the delay and the date by which we will complete action on the request. We may deny the request for amendment if the information contained in the record was not created by us, unless you provide a reasonable basis for believing the originator of the information is no longer available to act on the requested amendment; is not part of the medical record maintained by Provider; is not part of the information available for you to inspect; or the record is accurate and complete. If we deny your request for amendment, you will receive a timely, written denial in plain language that explains the basis for the denial, your rights to submit a statement disagreeing with the denial, and an explanation of how to submit that statement.

• Right to receive an accounting of disclosures: You have the right to request an accounting of the disclosures we have made of your health information for up to the past six (6) years. The accounting excludes disclosures for treatment, payment, or health operations and other applicable exceptions. We will provide the accountings within sixty (60) days of receipt of a written request. However, we may extend the time period for providing the accounting by thirty (30) days if, within the initial sixty (60) days, we provide you with a written statement of the reasons for the delay and the date by which you will receive the information. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests within the same 12-month period may be subject to a reasonable cost-based fee, which fee information will be provided to you in advance of fulfilling your request. You will also have an opportunity, upon receipt of fee information, to withdraw or modify your request for the accounting in order to avoid or reduce the applicable fee.

• Right to a paper copy of this notice: We reserve the right to amend this notice of privacy practices at any time.

• Right to receive notice of a breach: We are required to provide you with notice of any acquisition, access, use, or disclosure of unsecured Protected Health Information by Provider, its business associates, and/or subcontractors. Unsecured health information is information that is not secured by an electronic method specified by the government. Notice must be given within 60 days of the breach and will include a brief description of the breach and your information involved, steps you may take to protect your information, steps we are taking to investigate, mitigate loss, and protect against future breaches, and contact information where you may ask questions.

COMPLAINTS:

If you believe that your privacy rights have been violated, you may complain to Provider and/or to the Secretary of the U.S. Department of Health and Human Services at https://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.html. There will be no retaliation against you for filing a complaint. The complaint may be filed online with HHS. Complaints to Provider should be filed in writing and should state the specific incident(s) in terms of subject, date, and other relevant matters.

To file a complaint by mail:

Destiny Dental:
Email: contact@destinydentalcare.com
Mail: Destiny Dental
c/o Compliance
137 North Oak Park Ave. Suite 310
Oak Park, IL 60301

U.S. Department of Health and Human Services:
Attn.: Office of Civil Rights
200 Independence Ave. SW
Washington, D.C. 20201

CHANGES TO THIS NOTICE:

This notice is effective January 2019. We are required to abide by the terms of the notice currently in effect, but we reserve the right to change these terms as necessary. If we change the terms of this notice (while you are receiving service), we will promptly revise and distribute a revised notice to you as soon as practicable by mail, email (if you have agreed to electronic notice), hand delivery, or by posting on our website at www.destinydentalcare.com.