We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 08-01-2019, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice. please contact us using the information listed at the end of this notice.


We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

-Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders or to contact you if appointments are missed or need to be rescheduled (such as our confirmation system which includes text and/or email). We use SMS messaging and email to help our patients manage their appointments which may use or disclose your health information to easily convey information and enhance your experience. You may receive messages about your appointments based on your appointment activity. If you have any questions about your text or data plan, contact your wireless provider. If you choose to disclose your PHI and text/email communications to us, you implicitly grant us permission to respond to your communication—which may involve your health information.

Please advise us (preferable in text or writing) if these courtesies are not desired.

-Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. We may seek opinions and input from other dental specialists regarding your care, to facilitate treatment planning. At the start and during the course of your treatment, our office may share information with other dental and/or medical physicians necessary in the case. The staff obtains treatment information about you and records it in a health record.

-Payment: We may contact your insurance company to determine your eligibility and health insurance benefits for proposed treatment. We submit a request for preauthorization, in some cases, and for payment to your health insurance company. The health insurance company may request information from us regarding your dental care given. We will provide information necessary to facilitate insurance payment for the service.

-Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

-Your Authorization: In addition to our use of your health information for treatment, payment or healthcare 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 an authorization, you may 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. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

-To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

-Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

-Marketing Health-Related Services: We will not use your health information for marketing communications without your authorization.

-Other Uses: Images of you may be used on social media or in social settings if you choose to sign our social media consent form. This form will be given to you prior to your appointment. If you choose not to sign the form, or decline to consent, we will not distribute or use images of you in any social setting or social media platform. Please advise us in writing if at any time your wishes change. In addition. our informed consent policy covers the use of records, including photographs made in the process of examinations, treatment, and retention, for purposes of professional consultations, research, education, or publication in professional journals.

-Required by Law: We may use or disclose your health information when we are required to do so by law.

-Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim 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 authorities the health information of Armed Forces personnel under certain circumstances. We may disclose, to authorized federal officials, health information required for lawful intelligence, counterintelligence. and other national security activities. We may disclose to correctional Institution or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.


-Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to the address at the end of this Notice to obtain access to your health information. You may obtain a form to request access by contacting the Privacy Officer listed at the end of this Notice. We may charge a reasonable fee, established by the State of Washington, for expenses such as copying, staff time and model duplication. If you prefer, we will prepare a summary or an explanation of your health information for a fee.

-Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment. payment, healthcare operations and certain other activities. Disclosure accounting will commence April 14, 2003. Such requests must be made in writing, if you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to family members of

friends in the course of providing care.

-Restriction: You have the right to request, in writing, that we place additional restrictions on our use or disclosure of your health information. We are not required

to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

-Alternative Communication: You have the right to request. In writing, that we communicate with you about your health Information by alternative means or to alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request

-Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice In written form.


If you want more information about our privacy practices or have questions or concerns, please contact us at the information provided below.

If you are concerned that we may have violated your privacy, or you disagree with a decision we made about access to your 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 also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your 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.


Privacy Officer: Thalia-Rae Perryman
Email: [email protected]
Address: 1625 SE 192nd Ave Suite 205, Camas, WA 98607