Office Privacy Policies

This notice describes the privacy policies of this dental office. First and foremost, we strive to maintain confidentiality as far as your dental information must be disclosed to specific entities such as your insurance carrier. Herein we describe how this confidential dental and health information is used and disclosed and how you can gain access to this confidential information.
Background Information:
Dental offices are required by applicable federal and state laws to maintain confidentiality of dental health information generated for patients during the course of treatment. Through recent legislation, dental offices are now required to notify all patients about privacy practices, our legal duties concering these practices, and your rights concerning your health information. These office privacy policies take effect as of April 14, 2003 and will remain in effect until amended by this office.
We reserve the right to change the privacy practices of this office and the terms of this notice at any time, provided that such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices effective for all health information that we collect and maintain, including prior dental information as well as information gathered before policy chages are determined to be necessary. As changes in our privacy practices are made, we will notify our patients of these changes and make amended Office Privacy Policy statements available upon request.
Our patients are welcome to request copies of our office privacy policies at any time. Please keep this information on file with other documents from this office and check with our receptionist or office manager for any amended versions or changes.

Uses and Disclosures of Health Information

This office uses and discloses health information about you and/or family members for purposes of treatment, payment and dental practice operations. For example:
We may use or disclose your dental health information to dental colleagues, your physician or other health care providers rendering treatment.
We may use or disclose your dental treatment information through regular mail, fax, or electronic transmission to your dental insurance carrier to obtain payment for services rendered. Limited treatment information may also be disclosed to billing services that assist the office in preparing monthly statements.
Dental Practice Operations:
We may use and disclose your health information in conjunction with our health care operations, which include quality assessment and improvement activities, reviewing the competence or qualifications of personnel who work in this office, evaluating performance, conducting training programs within this office, accredidation, certification, licensing or credentialing activities. Your health information may also be disclosed to our attorneys and consultants as necessary to respond to any type of investigation or legal action pertaining to the quality of treatment provided to you.
Your Authorization:
In addition to our use of your health information for treatment, payment, or dental practice operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us such an authorization, you have the right to revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.
Disclosure to Family and Friends:
You have the right for us to disclose your own personal dental health information to you as described in the Patient Rights section of our Privacy Policies. We may also disclose your dental health information to a family member, friend, or other person to the extent necessary to help with your dental care or with payment for you dental care, but only if you agree that we may do so.
Persons Involved in Care:
We may use or disclose dental health information to identify or assist in the identification of you or a family member in conjunction with a forensic investigation. In the event of your incapacity or in emergency circumstances, we will disclose health information based on our professional judgement. In that instance, we will disclose only that information that is directly relevant to the treating entity’s involvement in your health care. We will also use our professional judgement and experience to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, dental supplies, x-rays, or other similar forms of health information.
We will not use your dental health information or images of your face and/or teeth for marketing communications without your specific written authorization to do so.
We may use or disclose your health information when we are required to do so by law through subpoena.
Abuse or Neglect:
We may disclose dental information of minor patients to appropriate authorities if we have reason to believe that they are possible victims of abuse, neglect or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security:
We may disclose to military authoritites the dental health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials dental information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose dental information to correctional institution or law enforcement offcials having lawful custody of protected dental information of inmates or patients under certain circumstances.
Appointment Reminders:
We may use or disclose basic dental information insofar as the fact that you have a dental appointment scheduled in the form of appointment reminders such as voicemail messages, postcards, letters, or e-mail messages.
Minimal Necessary Disclosures:
We will not make disclosures of your health information to a greater degree than we consider minimally necessary for the purpose of each disclosure.

Patient Rights

You have the right to read over or obtain copies of your dental health informtaion, with limited exceptions. Utah Law (R-156-69-502(7)) specifies that original records must remain in possession of the treating dentist for seven years, but you may request copies. You may request in person or in writing to obtain access to your dental information. You will be charged a reasonable cost-based fee for expenses such as copies and staff time. You will be asked to sign a brief authorization to obtain copies of your records. For written copies, you may be charged up to $0.75 for each page up to thirty (30) and $0.50 for each page after thrity; a $15.00 administrative fee to locate and copy your health information; and postage if you want copies mailed to you. Radiographs (x-rays) will be duplicated at a reasonable fee related to costs generated by this office to produce copies. Study models (dental casts) will also be duplicated for a reasonable fee related to costs of materials and time spent in duplicating the originals. Photographs and slides can also be duplicated at cost. If you prefer, we will prepare a summary or a written explanation of your health information for a fee related to the complexity of the summary. You may contact the privacy officer listed at the end of this Notice for a full explanation of our duplication fee structure.
Disclosure Frequency:
You have the right to receive a list of instances in which this practice disclosed your dental information for purposes other than treatment, payment, dental practice operations, and certain activities for the six month period starting April 15, 2003 and at any six month interval thereafter. If you request this accoutning more than once in a twelve month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
You have the right to request that we place additional restrictions on our use of disclosure of your dental health information. We reserve the right to discuss your request and we are not required to agree to your additional restrictions. If we agree to abide by your request, however, we may be exempted from this agreement in the event of an emergency.
Alternative Communication:
You have the right to request that we communicate with you about your dental health information by alternative means to alternative locations (fax or e-mail, for example). You must make your request in writing. Your request must specify the alternative means or location.
You have the right to request that we amend your dental health information that has been provided to you. Your request must be in writing and it must explain why the information should be amended. We reserve the right to deny your request under certain circumstances.
Electronic Notice:
If you first reviewd our privacy policies on our web site(s) or by e-mail you are entitled to receive this Notice in written form upon your request.

Questions and Complaints

If you want additional information about our privacy policies or have questions or concerns, you should contact our privacy officer listed below.
If you believe or are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your dental health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You may also correspond with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your dental health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Notice of Privacy Practices
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, are kept properly 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 “HIPAA,” 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 may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations.
  • Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An 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 service. 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 health-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 on your authorization.


You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:


  • The right to request restrictions on certain uses and disclosures of 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 resprect to protected health information.


This notice is effective as of April 14th, 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 provision effective for all protected helath information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

 You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaints 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.

Office Privacy Officer: Ann Gilbert
5685 S. 1475 E.
Suite 1-A
South Ogden, UT 84403
Office Telephone: (801) 476-7299
Office Fax: (801) 475-8019



For more information about HIPAA or to file a complaint:

The U.S. Department of Health & Human Services

Office of Civil Rights

200 Independence Avenue, S.W.

Washington, D.C. 20201

Phone: (202) 619-0257

Toll Free: (877) 696-6775


Better Health Care is Our Mission


(801) 476-7299

5685 S 1475 E, Ste. 1-A Ogden , UT , 84403