Notice of Privacy Practices
Maidstone Dental 7780 Invicta Ln, New Kent, VA 23124 Phone: (804) 966-8115 | Email: smile@maidstonedental.net
THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED BY MAIDSTONE DENTAL AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
YOUR RIGHTS
When it comes to your health information, you have certain rights. This section explains those rights.
Upon written request, you may:
See or get a copy of your health record. You may request an electronic or paper copy of your dental records or other health information we have about you. We will also provide a summary if requested. We charge a reasonable, cost-based fee. We will respond as soon as possible and no later than 30 working days after receiving your request.
Ask us to correct your health information. If you believe information in your record is incorrect or incomplete, you may ask us to correct it. We may say "no," but we will tell you why in writing within 60 days.
Request confidential communications. You can ask us to contact you in a specific way (for example, by home phone rather than cell phone) or to send mail to a different address. We will accommodate all reasonable requests.
Ask us to limit what we use or share. You may ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if doing so would affect your care.
Request restrictions on sharing with your insurer. If you pay for a service or dental care item entirely out of pocket and ask us not to share that information with your health insurer, we will honor that request, unless we are required by law to share it.
Get a list of those with whom we've shared your information. You may ask for an accounting of the times we have shared your health information for reasons other than treatment, payment, or healthcare operations. We will provide a list covering the past six years. The first request each year is free; additional requests may carry a reasonable, cost-based fee.
Revoke an authorization. You may revoke a prior written authorization at any time, except where action has already been taken based on that authorization.
You may also:
Appoint someone to act on your behalf. If you have granted someone medical power of attorney, or if they are your legal guardian, that person may exercise your rights and make decisions about your health information. We will ask for proof of this relationship before taking any action.
Get a paper copy of this notice at any time, even if you agreed to receive it electronically. We will provide it promptly.
File a complaint if you believe your privacy rights have been violated. Contact our Privacy Officer (see below), or file with the U.S. Department of Health and Human Services Office for Civil Rights: 200 Independence Ave, S.W., Washington, D.C. 20201 | 1-877-696-6775 | www.hhs.gov/ocr/privacy/hipaa/complaints. We will not retaliate against you for filing a complaint.
YOUR CHOICES
For certain health information, you can tell us your preferences about what we share. If you have a clear preference in the situations described below, please let us know.
You have both the right and the choice to tell us to share information with your family members, close friends, or others involved in your care, and to share information in a disaster relief situation.
If you are unable to tell us your preference (for example, if you are unconscious) we may 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 the following information without your written permission: information used for marketing purposes, the sale of your information, or psychotherapy notes (if applicable).
OUR USES AND DISCLOSURES
We typically use or share your health information in the following ways:
Treatment: We may use your health information and share it with other professionals involved in your care. For example, we may share your records with a specialist when providing a referral, or send reports to other treating providers to assist with your care.
Payment: We may use or share your health information to bill and receive payment from your dental insurance plan or other entities. For example, we submit information to your insurer so it will pay for services you receive.
Health Care Operations: We may use and share your health information to run our practice, improve your care, and contact you when necessary. For example, we use your information to manage your treatment, conduct quality reviews, and send appointment reminders.
Other permitted uses and disclosures include:
Public health and safety: Preventing disease, assisting with product recalls, reporting adverse drug reactions, reporting suspected abuse or neglect, or preventing a serious threat to health or safety.
Compliance with the law: When required by state or federal law, including disclosures to HHS for HIPAA compliance reviews.
Organ and tissue donation: As required, with organ procurement organizations.
Medical examiners and funeral directors: When necessary following a patient's death.
Workers' compensation and government requests: For workers' compensation claims, law enforcement purposes, health oversight activities, and special government functions such as military or national security activities.
Lawsuits and legal actions: In response to a court order, administrative order, or lawful subpoena.
Research: For health research conducted in compliance with applicable law and ethical standards.
OUR RESPONSIBILITIES
The law requires us to: maintain the privacy and security of your protected health information; notify you promptly if a breach occurs that may compromise your information; follow the duties and privacy practices described in this notice; and not use or share your information in ways other than what is described here unless you provide written approval. If you later change your mind, notify us in writing and we will stop the use or disclosure to the extent we are able.
CHANGES TO THIS NOTICE
We may change the terms of this notice at any time. Changes will apply to all health information we hold about you. The updated notice will be available upon request, in our office, and on our website at maidstonedental.net.
CONTACT OUR PRIVACY OFFICER
If you have questions about this notice or wish to exercise any of your rights, please contact:
Privacy Officer, Maidstone Dental 7780 Invicta Ln, New Kent, VA 23124 Phone: (804) 966-8115 Email: smile@maidstonedental.net
Effective Date: May 30, 2025
This notice meets the requirements of the HIPAA Privacy Rule and the 2013 Omnibus Rules.
Please do not submit sensitive medical or insurance information through this form. If you are experiencing a dental emergency, call our office directly at (804) 966-8115.