Notice of Privacy Practices
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.
Effective Date: March 1, 2026
Memphis Dental Studio is required by law to maintain the privacy of your protected health information (PHI), to provide you with this notice of our legal duties and privacy practices, and to abide by the terms of this notice currently in effect.
How We May Use and Disclose Your Health Information
Treatment
We may use and disclose your PHI to provide, coordinate, or manage your dental care and related services. For example, we may share information with a specialist to whom we refer you, or with a laboratory that analyzes X-rays taken in our office.
Payment
We may use and disclose your PHI to obtain payment for services we provide to you. For example, we may submit claims to your dental insurance company and include information about the treatment you received.
Healthcare Operations
We may use and disclose your PHI for our healthcare operations, such as quality assessment, staff training, business planning, and administrative functions necessary to run our practice.
Other Permitted Uses and Disclosures
We may also use or disclose your PHI in the following circumstances without your authorization:
- As required by law, including public health activities and reporting requirements
- To report suspected abuse, neglect, or domestic violence to appropriate authorities
- For health oversight activities by governmental agencies
- In response to a court or administrative order, subpoena, or other legal process
- For law enforcement purposes as required or permitted by law
- To coroners, medical examiners, or funeral directors as permitted by law
- For organ, eye, or tissue donation purposes
- For certain research activities under specific conditions
- To avert a serious threat to health or safety
- For workers' compensation or similar programs
- To business associates who perform functions on our behalf under a written Business Associate Agreement
Your Rights Regarding Your Health Information
Right to Inspect and Copy
You have the right to inspect and obtain a copy of your PHI that is contained in a designated record set, such as dental records and billing records. To request access, submit a written request to our office. We may charge a reasonable fee for copies.
Right to an Amendment
If you believe information in your record is incorrect or incomplete, you may request that we amend it. Submit your request in writing, including the reason for the amendment. We may deny the request under certain circumstances and will explain the reason in writing.
Right to an Accounting of Disclosures
You have the right to request a list of disclosures we made of your PHI in the six years prior to your request, except for disclosures made for treatment, payment, or healthcare operations, or disclosures you authorized. Submit your request in writing.
Right to Request Restrictions
You may request that we restrict how we use or disclose your PHI. We are not required to agree to your request, but if we do agree, we will honor it except in emergencies. If you pay out of pocket in full for a service, you may request that we not share information about that service with your health plan.
Right to Request Confidential Communications
You may request that we contact you at a specific location or by a specific method (e.g., only by mail to a certain address). We will accommodate reasonable requests.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this notice at any time, even if you have agreed to receive it electronically. Contact our office to request a printed copy.
Our Duties
We are required by law to:
- Maintain the privacy of your protected health information
- Provide you with this notice of our legal duties and privacy practices
- Notify you following a breach of your unsecured PHI
- Abide by the terms of this notice currently in effect
We reserve the right to change our privacy practices and the terms of this notice. Any changes will apply to PHI we already have as well as new information. If we make a material change, we will post the revised notice in our office and on our website. You may request a copy of the current notice at any time.
Uses and Disclosures Requiring Your Authorization
All other uses and disclosures of your PHI not described in this notice require your written authorization. You may revoke your authorization in writing at any time, except to the extent that we have already acted in reliance upon it.
How to File a Complaint
If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services (HHS) Office for Civil Rights. To file with HHS, visit hhs.gov/ocr or call 1-800-368-1019 (TDD: 1-800-537-7697). We will not retaliate against you for filing a complaint.
To file a complaint with our office, contact us in writing:
Dr. Haneen — Privacy Officer, Memphis Dental Studio
9755 US Highway 64 Ste 104, Arlington, TN 38002
Email: smile@memphisdentalstudio.com
Phone: (901) 902-5335
Contact for Questions
If you have questions about this notice or our privacy practices, please contact us at the address above. A copy of this notice is available at our front desk and upon request.