Effective Date: January 1, 2026

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 January 1, 2026, 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:

We may use or disclose your health information to a physician or other healthcare provider providing treatment to you, including specialists, oral surgeons, laboratories, or other dentists involved in your care. We may also contact you to provide appointment reminders or information about treatment alternatives or other health-related services that may be of interest to you.

We may use and disclose your health information to obtain payment for the dental services we provide. This includes billing and collecting from you, your dental insurance plan, or a third-party payer. For example, we may need to share information about dental treatment you received at our office with your insurance company in order to process a claim, obtain pre-authorization, or determine your eligibility for benefits. We may also share your health information with billing and collection companies, insurance companies, health plans, and other entities as needed for payment purposes.

We may use and disclose your health information for our healthcare operations. These activities include, but are not limited to, quality assessment and improvement activities, employee training and education, compliance programs, audits, accreditation, certification, licensing activities, business planning, and general administrative activities. We may also share your health information with third parties who assist us with our healthcare operations, provided they agree to appropriate safeguards for your information.

We are required by Michigan law to obtain your written consent prior to making certain disclosures of your health information.

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 disclosure permitted by your authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

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.

We may use or disclose health information to notify, or assist in the notification of, 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, we will provide you with an opportunity to object to such uses or disclosures before they are made. 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 directly relevant to the person's involvement in your healthcare.

We will not use your health information for marketing communications without your written authorization.

We may use or disclose your health information when we are required to do so by law, including for public health activities, health oversight activities, judicial and administrative proceedings, law enforcement purposes, serious threats to health or safety, workers' compensation, organ and tissue donation, and research with appropriate institutional review board approval.

We may use or disclose your health information to provide you with appointment reminders such as voicemail messages, postcards, text messages, or letters.

You have the following rights with respect to your protected health information:

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 obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $1.00 for each page and $50.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure. In certain limited circumstances, we may deny your request. If we deny your request, we will provide you with a written explanation and inform you of your right to have the denial reviewed.

You have the right to request that we amend your health information if you believe the information in your records is incorrect or incomplete. To request an amendment, you must submit a written request to our office that includes the reason you are requesting the amendment. We may deny your request if, for example, the information was not created by us, is not part of the information you would be permitted to inspect and copy, or if we determine that the information is accurate and complete. If we deny your request, we will provide you with a written explanation.

You have the right to request an accounting of certain disclosures of your health information that we have made. This accounting will not include disclosures made for treatment, payment, or healthcare operations; disclosures made with your written authorization; or disclosures made directly to you. To request an accounting, you must submit a written request to our office specifying the time period, which may not go back more than six years and may not include dates before April 14, 2003. The first accounting in a 12-month period will be provided free of charge. Additional requests within the same period may be subject to a reasonable cost-based fee.

You have the right to request that we restrict or limit how we use or disclose your health information for treatment, payment, or healthcare operations. We are not required to agree to your request for restrictions, except that we are required to agree to restrict disclosures to a health plan if the disclosure is for payment or healthcare operations (and not for treatment), and the information pertains solely to a healthcare item or service for which you have paid us out of pocket in full. To request a restriction, you must submit a written request to our office.

You have the right to request that we communicate with you about your health matters in a certain way or at a certain location. For example, you may request that we contact you only at your work phone number or by mail to a specific address. To request confidential communications, you must submit a written request to our office specifying how or where you wish to be contacted. We will accommodate all reasonable requests.

You have the right to receive a paper copy of this Notice of Privacy Practices at any time, even if you have previously received a copy or agreed to receive this Notice electronically. To obtain a paper copy, please contact our office at (616) 245-9830 or request one in person at our front desk.

We are required by law to maintain the privacy and security of your protected health information. We are required to provide you with this Notice of our legal duties and privacy practices with respect to your health information. We are required to abide by the terms of this Notice as currently in effect. We are required to notify you if a breach occurs that may have compromised the privacy or security of your unsecured protected health information. In the event of such a breach, we will notify you as required by law. We will not use or disclose your health information without your written authorization, except as described in this Notice. We will not use or disclose your health information for marketing purposes or sell your health information without your prior written authorization. We reserve the right to change our privacy practices and to make the new provisions effective for all health information that we maintain, including health information we created or received before the changes. When we make a significant change in our privacy practices, we will revise this Notice and make the new Notice available upon request and in our office.

If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights 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 may also 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 the U.S. Department of Health and Human Services.

Office Contact: Please ask for the Privacy Officer of our office. Telephone: (616) 245-9830. Fax: (616) 245-5026. Address: 2003 Burton St SE, Grand Rapids, MI 49506.

Patient Acknowledgment of Receipt

By signing below, I acknowledge that I have received a copy of this Notice of Privacy Practices from Eastgate Family Dental.