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.

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health  information and what rights you have regarding it.  

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

The most common reason why we use or disclose your health information is for treatment, payment, or  health care operations. Examples of how we use or disclose information for treatment purposes are:  setting up an appointment for you; examining your teeth; prescribing medications and faxing them to be  filled; referring you to another doctor or clinic for other health care or services; or getting copies of your  health information from another professional that you may have seen before us. Examples of how we use  or disclose your health information for payment purposes are: asking you about your health or dental  care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid  amounts (either ourselves or through a collection agency or attorney). "Health care operations" mean  those administrative and managerial functions that we have to do in order to run our office. Examples of  how we use or disclose your health information for health care operations are: financial or billing audits;  internal quality assurance; personnel decisions; participation in managed care plans; defense of legal  matters; business planning; and outside storage of our records.

We routinely use your health information inside our office for these purposes without any special  permission. If we need to disclose your health information outside of our office for these reasons, we  usually will not ask you for special written permission.

Special Protections for Substance Use Disorder (SUD) Records

For patients receiving treatment for substance use disorders, federal law (42 CFR Part 2) provides  additional privacy protections beyond standard health information.

• Heightened Confidentiality: We will not disclose records identifying you as having a substance use  disorder in civil, criminal, administrative, or legislative proceedings without your specific written  consent or a specialized court order.
• Single Consent for TPO: You may choose to provide a single, written "Global Consent" that allows  us to use and disclose your SUD records for all future treatment, payment, and health care  operations.
• Right to Revoke: You have the right to revoke this consent at any time in writing, except to the  extent that we have already taken action based on your prior permission.
• Accounting of Disclosures: You have the right to request a list of certain disclosures of your SUD  records made for treatment, payment, and health care operations for the three years prior to your  request.
• Prohibition on Redisclosure: Anyone receiving your SUD records is generally prohibited from  sharing that information further unless you provide express written consent or the law  specifically permits it.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

In some limited situations, the law allows or requires us to use or disclose your health information  without your permission. Not all of these situations will apply to us; some may never come up at our  office at all. Such uses or disclosures are:

• when a state or federal law mandates that certain health information be reported for a specific  purpose;
• for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;  
• disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
• uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by  Medicare or Medicaid; or for investigation of possible violations of health care laws;
• disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders  of courts or administrative agencies;
• disclosures for law enforcement purposes, such as to provide information about someone who is or  is suspected to be a victim of a crime; to provide information about a crime at our office; or to  report a crime that happened somewhere else;
• disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to  funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
• uses or disclosures for health-related research;
• uses and disclosures to prevent a serious threat to health or safety;
• uses or disclosures for specialized government functions, such as for the protection of the President  or high-ranking government officials; for lawful national intelligence activities; for military  purposes; or for the evaluation and health of members of the foreign service;
• disclosures of de-identified information;
• disclosures relating to workers’ compensation programs;
• disclosures of a "limited data set" for research, public health, or health care operations;
• incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
• disclosures to "business associates" who perform health care operations for us and who commit to  respect the privacy of your health information;

Unless you object, we will also share relevant information about your care with your family or friends  who are helping you with your dental care.  

NOTIFICATION OF DATA BREACHES

We are required by law to maintain the privacy and security of your protected health information. In the  event of a breach—which is the unauthorized acquisition, access, use, or disclosure of your unsecured  health information—we will notify you promptly. This notice will be provided in writing via first-class  mail (or via email if you have previously agreed to electronic communications) and will include a  description of what happened, the types of information involved, and the steps we are taking to  investigate the breach, mitigate losses, and protect against further occurrences.

APPOINTMENT REMINDERS

We may call or write to remind you of scheduled appointments, or that it is time to make a routine  appointment. We may also call or write to notify you of other treatments or services available at our  office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a  postcard, and/or leave you a reminder message on your home answering machine or with someone who  answers your phone if you are not home.

TELEHEALTH / VIRTUAL VISITS AND ELECTRONIC COMMUNICATIONS

From time to time, we may offer telehealth (virtual) visits or communicate with you electronically (for  example, through a patient portal, secure video, email, or text) to provide care, answer questions,  coordinate treatment, send reminders, or discuss billing matters. When we provide telehealth services,  we may use technology vendors to help us deliver these services. These vendors may receive limited  protected health information as needed to provide the service and are required to protect your  information and may be required to sign a business associate agreement with us, as applicable. You may  request that we communicate with you in a confidential way (for example, using a specific phone number, mailing address, email address, or through the patient portal). See the “Confidential  Communications” right described in the Notice. Please tell us if you want to opt out of electronic  communications or prefer a different method. Electronic communications can carry some risk of  interception or misdelivery. We use reasonable safeguards to protect your information, and we  encourage you to use secure methods (such as the patient portal) when available. If you choose to  communicate with us by unencrypted email or text, you are acknowledging and accepting those risks. If  you have questions about telehealth or electronic communications, contact the office contact person  listed at the beginning of the Notice.  

OTHER USES AND DISCLOSURES  

We will not make any other uses or disclosures of your health information unless you sign a written  "authorization form." The content of an "authorization form" is determined by federal law. Sometimes,  we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may  initiate the process if it's your idea for us to send your information to someone else. Typically, in this  situation you will give us a properly completed authorization form, or you can use one of ours. If we  initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we  cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have  already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person  named at the beginning of this Notice.

Uses and Disclosures Requiring Your Authorization  

Most uses and disclosures of your health information for marketing purposes, and disclosures that  constitute a sale of your health information, require your written authorization. Other uses and  disclosures not described in this Notice will be made only with your written authorization. You may  revoke such an authorization at any time in writing.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

The law gives you many rights regarding your health information. You can:

• ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment),  payment or health care operations. We do not have to agree to do this, but if we agree, we must  honor the restrictions that you want. To ask for a restriction, send a written request to the office  contact person at the address, fax or email shown at the beginning of this Notice.
• ask us to communicate with you in a confidential way, such as by phoning you at work rather than  at home, by mailing health information to a different address, or by using email to your personal  email address. We will accommodate these requests if they are reasonable, and if you pay us for  any extra cost. If you want to ask for confidential communications, send a written request to the  office contact person at the address, fax or email shown at the beginning of this Notice.
• ask to see or to get photocopies of your health information. By law, there are a few limited situations  in which we can refuse to permit access or copying. For the most part, however, you will be able to  review or have a copy of your health information within 30 days of asking us (or 60 days if the  information is stored off-site). You may have to pay for photocopies in advance. If we deny your  request, we will send you a written explanation, and instructions about how to get an impartial  review of our denial if one is legally available. By law, we can have one 30-day extension of the time  for us to give you access or photocopies if we send you a written notice of the extension. If you want  to review or get photocopies of your health information, send a written request to the office contact  person at the address, fax or email shown at the beginning of this Notice.
• ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health  information along with any rebuttal statement that we may write. Once your statement of position  and/or our rebuttal is included in your health information, we will send it along whenever we make  a permitted disclosure of your health information. By law, we can have one 30-day extension of  time to consider a request for amendment if we notify you in writing of the extension. If you want  to ask us to amend your health information, send a written request, including your reasons for the  amendment, to the office contact person at the address, fax or email shown at the beginning of  this Notice.
• get a list of the disclosures that we have made of your health information within the past six years  (or a shorter period if you want). By law, the list will not include: disclosures for purposes of  treatment, payment, or health care operations; disclosures with your authorization; incidental  disclosures; disclosures required by law; and some other limited disclosures. You are entitled to  one such list per year without charge. If you want more frequent lists, you will have to pay for them  in advance. We will usually respond to your request within 60 days of receiving it, but by law we  can have one 30-day extension of time if we notify you of the extension in writing. If you want a  list, send a written request to the office contact person at the address, fax or email shown at the  beginning of this Notice.
• get additional paper copies of this Notice of Privacy Practices upon request. It does not matter  whether you got one electronically or in paper form already. If you want additional paper  copies, send a written request to the office contact person at the address, fax or email shown at  the beginning of this Notice.
• Restrict Disclosures for Out-of-Pocket Payments: If you pay for a dental service or health care item  out-of-pocket in full, you have the right to ask us not to share that information with your dental  insurance or health plan for the purposes of payment or our operations. We are legally required  to agree to this request unless a law requires us to share that information.

OUR NOTICE OF PRIVACY PRACTICES

By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We  reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new  privacy practices will apply to your health information that we already have as well as to such  information that we may generate in the future. If we change our Notice of Privacy Practices, we will post  the new notice in our office, have copies available in our office, and post it on our website.

COMPLAINTS

If you think that we have not properly respected the privacy of your health information, you are free to  complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will  not retaliate against you if you make a complaint. If you want to complain to us, send a written  complaint to the office contact person at the address, fax or email shown at the beginning of this Notice.  If you prefer, you can discuss your complaint in person or by phone.

FOR MORE INFORMATION

If you want more information about our privacy practices, call or visit the office contact person at the  address or phone number shown at the beginning of this Notice.

Effective date of this Notice: 02/06/2026  
Privacy Official: Deana Fugate 574-533-6911
1213 West Lincoln Avenue Goshen, Indiana 46526 frontdesk@goshensmiles.com