Effective Date: November 30, 2023The McHenry Dentist2964 Commerce DriveJohnsburg, Illinois, 60051(815) 363-0103
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND / OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The terms of this Notice of Privacy Practices (“Notice”) apply to The McHenry Dentist, its affiliates, and its employees. The McHenry Dentist will share patients’ protected health information as necessary to carry out treatment, payment, and health care operations as permitted by law.
We are required by law to maintain the privacy of our patient’s protected health information and to provide patients with Notice of our legal duties and privacy practices for protected health information.
We are required to abide by the terms of this Notice for as long as it remains in effect. We reserve the right to change the terms of this Notice as necessary and to make a new notice of privacy practices effective for all protected health information maintained by The McHenry Dentist.
We are required to notify you in the event of a breach of your unsecured protected health information. We are also required to inform you that there may be a provision of state law that relates to the privacy of your health information that may be more stringent than a standard or requirement under the Federal Health Insurance Portability and Accountability Act (“HIPAA”).
You may obtain a copy of any revised Notice of Privacy Practices or information pertaining to a specific State law by mailing a request to the Privacy Officer at the address below.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
We may use and disclose your Protected Health Information in the following situations:
USES AND DISCLOSURES IN WHICH YOU HAVE THE RIGHT TO OBJECT AND OPT-OUT
USES AND DISCLOSURES THAT REQUIRE YOUR WRITTEN AUTHORIZATION
We will not disclose or use your Protected Health Information in the situations listed below without obtaining written authorization. In addition to the uses and disclosures listed below, other uses not covered in this Notice will be made only with your written authorization. If you provide us with consent, you may revoke it at any time by submitting a request in writing:
PROTECTED HEALTH INFORMATION AND YOUR RIGHTS
The following are statements of your rights, subject to certain limitations, with respect to your Protected Health Information:
CHANGES TO THIS NOTICE
We reserve the right to change the terms of this notice and will notify you of such changes. We will also make copies of our new notice available if you wish to obtain one. We will not retaliate against you for filing a complaint.
If you believe your privacy rights have been violated, you can file a complaint in writing with the Privacy Officer. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services at the below address. There will be no retaliation for filing a complaint.
Office for Civil Rights Department of HHS Jacob Javits Federal Building 26 Federal Plaza – Suite 3312 New York, NY 10278
Voice Phone (212) 264-3313 FAX (212) 264-3039 TDD (212) 264-2355
For Further Information: If you have questions, need further assistance regarding or would like to submit a request pursuant to this Notice, you may contact the The McHenry Dentist Privacy Officer by phone at (815) 363-0103 or at the following address:
2964 Commerce DriveJohnsburg, Illinois, 60051
This Notice of Privacy Practices is also available on our The McHenry Dentist web page at https://themchenrydentist.com.