HIPAA Notice of Privacy Practices

Bracken Godfrey, DDS, MS 8 Clark Way, Somersworth, NH 03878 Effective Date of Notice: 7/1/21

This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully.

By law, our office is required to maintain the privacy and security of protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and to provide individuals with a Notice of our legal duties and privacy practices concerning PHI. Additionally, we will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

We will follow privacy practices that are described in the notice of privacy practices currently in effect and give you a copy of it. We reserve the right to change the terms of this notice, as allowed by the appropriate laws, which will be effective for all PHI we maintain. If we decide to make changes, we will make you aware by email and mailing. You may request a copy of our Notice at any time if you inquire about additional information about our privacy practices. For additional copies of this Notice, please contact us.

Our Uses and Disclosures

We are allowed to use your health information for purposes, including:

  • Treatment
    • E.g., to another dentist providing treatment or a pharmacist in order to fill a prescription
  • Health Care Operations
    • E.g., Quality assessment and improvement activities, training programs and licensing or credentialing activities
  • Payment
    • E.g., We may send claims to a dental health plan
  • Helping with Certain Public Health and Safety issues;
    • We can share health information about you for certain situations such as: Preventing disease, Helping with product recalls, Reporting adverse reactions to medications, Reporting suspected abuse, neglect, or domestic violence, Preventing or reducing a serious threat to anyone's health or safety.
  • Do Research;
    • We can use or share your information for health research.
    • Comply with the law;
      • We will share information about you if state or federal laws require
        it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.
    • Respond to organ and tissue donation requests;
      • We can share health information about you with organ procurement organizations.
    • Work with a medical examiner or funeral director
      • We can share health information with a coroner, medical
        examiner, or funeral director when an individual dies
    • Address workers compensation, law enforcement, and other government requests;
      • We can use or share health information about you: For worker's compensation claims; For law enforcement purposes or with a law enforcement official; With health oversight agencies for activities authorized by law; For special government functions such as military, national security, and presidential protective services.
    • We may also use your PHI to respond to comply with the law and lawsuits and legal actions
      • We can share health information about you in response to a court or administrative order, or in response to a subpoena

Other uses and disclosures not included in this notice will only be made with your written authorization.

Your Rights

You have the right to:

  • Ask us to correct the Medical record and Request confidential communications.
    • You can ask us to amend health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say "no" to your inquiry. but we will tell you why within 60 days.
  • Request Confidential Communication.
    • You can make reasonable requests to be contacted at different places or
      in a distinct way. We will say "yes" to all reasonable requests.
  • Request an electronic or paper copy of your medical record.
    • You can ask to see or get an electronic or paper copy of your medical record and other health information we possess. We will provide a copy or a summary of your health information. ordinarily within 60 days of your request or 60 days if we let you know about the extension. You may have to put your request in writing, including pay a reasonable cost for copying, mailing, supplies, and/or postage. And the staff time for copying and not for searching or retrieval of the information.
  • Ask us to limit what we use or share.
    • You can ask us not to use or share certain health information when it involves treatments, payments, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care confidentiality rights are compromised, and a licensed healthcare professional will review this denial at your request. If you pay for a service or health care item out of pocket in full, you can ask us not to share that information for payment or our operation switch health insurer. We will say "yes" unless a law requires us to share that information.
  • Request an accounting of disclosures.
    • You can ask for a list of the times we have shared your health information for a six-year before the date you ask, whom we shared it with, and who. We will incorporate all the disclosures. Besides treatment, payment, and health care operations, also several other disclosures. We will provide one accounting a year free. We will charge a reasonable. cost-based fee if you ask for another one within 12 months, for marketing purposes, Sale of your information, Most sharing of psychotherapy notes.
  • Get a copy of this Privacy 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.
  • Choose someone to act for you.
    • If you have given someone medical power of attorney or someone 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 considering any action.
  • File a complaint if you feel your rights are Violated
    • You can complain if you believe we have violated your rights. You can file a complaint with the U.S Department of Health and Human Services, Office for Civil Rights by sending a letter to 200 Independence Avenue, S. W., Washington, D.C. 20201, calling 1 {800)-696-6775, or visit www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

Your Choices

You have certain choices when it comes to your personal health information. You have both the right and the choice regarding:

  • Sharing information with your family, close friends, or others involved in your care or involved in paying for your treatment. o
  • Sharing information in a disaster relief situation.
  • We will not share any substance abuse, HIV, or genetic information, in the unusual event we collect it without your specific consent.
    • This organization does not provide psychotherapy or maintain a patient directory
  • If you are incapable of letting us know your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

We will never share your information unless you give us your written permission for marketing purposes or selling your data.

HIPAA Office Contact Information

HIPAA Entity:
Civil Rights Coordinator:
Civil Rights Coordinator Title:
TTY (if applicable):